WORLD

MALARIA

REPORT 2013

WORLD MALARIA REPORT

WHO GLOBAL MALARIA PROGRAMME

2013

WHO Library Cataloguing-in-Publication Data World malaria report : 2013. 1.Malaria - prevention and control. 2 Malaria - economics. 3.Malaria - epidemiology. 4.National health programs - utilization. 5.Insecticidetreated bednets. 6.Antimalarials - therapeutic use. 7.Drug resistance. 8.Disease vectors. 9.Malaria vaccines. 10.World health. I.World Health Organization. ISBN 978 92 4 156469 4 World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for non-commercial distribution should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Map production: WHO Global Malaria Programme and WHO Public Health Information and Geographic Information Systems. Design and layout: designisgood.info Cover photo: Mark Tuschman (www.tuschmanphoto.com/blog) Inside photo: Mark Tuschman (www.tuschmanphoto.com/blog) Please consult the WHO Global Malaria Programme web site for the most up-to-date version of all documents (www.who.int/malaria). Printed in Switzerland (NLM classication: WC 765)

Contents
Foreword Acknowledgements Abbreviations Summary and Key Points Avant-propos Rsum et points essentiels Prefacio Resumen y puntos esenciales CHAPTER 1 Introduction CHAPTER 2 Policies, strategies, goals and targets for malaria control and elimination 2.1 Policy development 2.2 Malaria control policies and strategies 2.3 Malaria surveillance 2.4 Malaria elimination 2.5 Goals and targets for malaria control and elimination 2.6 Indicators of progress CHAPTER 3 Financing malaria control 3.1 International nancing of malaria control 3.2 Domestic nancing of malaria control 3.3 Comparison of resources available and resource requirements 3.4 Distribution of available funding by WHO Region 3.5 Distribution of available funding by disease burden and national income 3.6 Endemic countrys willingness to pay for malaria control 3.7 Conclusions CHAPTER 4 Vector control for malaria 4.1 Need for vector control 4.2 ITN/LLIN policy and implementation 4.3 IRS policy adoption and implementation 4.4 Larval control strategies 4.5 Malaria vector insecticide resistance and the Global Plan for Insecticide Resistance Management 4.6 Conclusions CHAPTER 5 Preventive therapies for malaria 5.1 Need for preventive chemotherapy 5.2 Malaria chemoprevention policies and implementation 5.3 New therapies for malaria prevention 5.4 Conclusions CHAPTER 6 Diagnostic testing and treatment of malaria 6.1 Needs for diagnostic testing and treatment 6.2 Diagnostic testing for malaria 6.3 Treatment of malaria 6.4 Antimalarial drug resistance 6.5 Conclusions CHAPTER 7 Malaria Surveillance 7.1 Introduction 7.2 Indicators derived from routine information systems 7.3 Indicators derived from household surveys 7.4 Conclusions CHAPTER 8 Changes in malaria incidence and mortality 8.1 Introduction 8.2 Progress towards elimination 8.3 Trends in estimated malaria cases and deaths 8.4 Conclusions Regional proles Country proles Annexes v vi viii ix xv xvi xxi xxiii 1 3 3 4 11 12 12 12 17 17 18 19 19 20 20 21 23 23 23 26 28 28 30 31 31 31 33 34 37 37 38 40 44 46 49 49 49 50 52 55 55 58 61 66 69 91 199

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If political commitment wanes, the great progress that has been achieved could be undone in some places in a single transmission season.

Foreword
Dr Margaret Chan Director-General World Health Organization
This years World Malaria Report documents remarkable progress in the global ght against malaria, and includes updated burden estimates for the 2000-2012 period. The report shows that increased political commitment and the expansion of global malaria investments since 2000 have led to major gains against this preventable disease, saving an estimated 3.3 million lives. Each year we have a better understanding of global malaria trends and the burden of disease, as measured against the situation in 2000. According to the latest estimates, malaria mortality rates were reduced by about 45% globally and by 49% in the WHO African Region between 2000 and 2012. During the same period, malaria incidence rates declined by 29% around the world, and by 31% in the African Region. These substantial reductions occurred as a result of a major scale-up of vector control interventions, diagnostic testing, and treatment with artemisinin-based combination therapies, or ACTs. This progress is no cause for complacency. The absolute numbers of malaria cases and deaths are not going down as fast as they could. The disease still took an estimated 627 000 lives in 2012, mostly those of children under ve years of age in Africa. This means 1300 young lives lost to malaria every day a strong reminder that victory over this ancient foe is still a long way o. The fact that so many people are dying from mosquito bites is one of the greatest tragedies of the 21st century. If political commitment wanes, the great progress that has been achieved could be undone in some places in a single transmission season. In the last few years, we have started seeing the rst signs of a potential slow-down. In 2011 and 2012, the delivery of long-lasting insecticidal nets to endemic countries slowed down and indoor residual spraying programmes levelled o. During this period, malaria mortality rates continued to go down but at a slower pace. In 2013, bednet deliveries picked up again, and the pipeline for next year is even stronger. Nonetheless, even greater eorts will be needed to protect everyone at risk. As the international community gradually moves towards a post-2015 development agenda, we must not lose sight of what the worlds most vulnerable populations expect from us. The concept of universal health coverage represents both a social value and an approach to health care that generates better health for entire populations, reduces social inequalities, and protects people from poverty induced by health-care costs. It is a key concept that is already at the centre of the global health debate, and also the debate about the next set of development goals. Progress against malaria provides good evidence of the tangible benets of population-wide access to life-saving interventions. The world also needs to stay focused on addressing the global funding gap for malaria prevention and control. The currently available funding is far less than required to reach universal access to malaria interventions. To achieve our goal, we need an accelerated eort in scaling up vector control tools. We also need to ensure that the most vulnerable groups children under ve, infants and pregnant women get access to WHO-recommended intermittent preventive therapies, where appropriate. While progress in expanding diagnostic testing and quality-assured treatment has been immense in recent years, we are far from achieving universal access. In addition, parasite resistance to artemisinin the core compound in the worlds most eective antimalarial medicines and mosquito resistance to insecticides remain major concerns. If not addressed with appropriate urgency, they could threaten the remarkable progress made since 2000. Though WHO has issued global strategies to tackle these challenges, progress in their adoption by countries has been slow, primarily due to inadequate nancing. In April 2013, on World Malaria Day, WHO launched an Emergency response to artemisinin resistance in the Greater Mekong subregion to guide countries in the scale-up and implementation of eorts to eliminate resistant parasites. The funding gap for this eort is also substantial. Strengthening health infrastructures, vital registration and surveillance systems is equally critical to further progress. Based on reported data, 59 countries are meeting the MDG target of reversing the incidence of malaria, and 52 countries are on track to reduce their malaria case incidence rates by 75%, in line with World Health Assembly and Roll Back Malaria targets for 2015. However, these 52 countries account for only 4%, or eight million, of the total estimated malaria cases around the world. In 41 endemic countries, including most high-burden countries, we cannot make a reliable assessment of malaria trends. A concerted eort to improve surveillance systems is needed to remove this gap in our understanding of the malaria situation. WHO is grateful for the commitment of ministries of health in endemic countries and their many development partners. We are condent that, if we remain determined and act with urgency, we can beat this ancient enemy once and for all.

WORLD MALARIA REPORT 2013 | v

Acknowledgements
We are very grateful to the numerous people who contributed to the production of the World malaria report 2013. The following people collected and reviewed data from malaria endemic countries: Ahmad Walid Sediqi, Ahmad Mureed Muradi and Sami Nahzat(Afghanistan); Hammadi Djamila (Algeria); Nilton Saraiva and Yava L. Ricardo (Angola); Mario Zaidenberg (Argentina); Viktor Gasimov (Azerbaijan); Mannan A. Bangali and Mohammad Jahirul Karim (Bangladesh); Kim Bautista (Belize); Mariam Ok-Sopoh (Benin); Pema Samup, Rinzin Namgay and Sonam Gyeltshen (Bhutan); Marcos Ysrael Fernandez Encinas (Bolivia [Plurinational State of ]); Simon Chihanga (Botswana); Mariana Pereira de Arajo and Poliana de Brito Ribeiro (Brazil); Patrice A. Combary (Burkina Faso); Mbanye Hypax (Burundi); Jlio Monteiro Roigues (Cabo Verde); Abdur Rashid, Siv Sovannaroth and Samphornarann Top (Cambodia); Kouambeng Celestin (Cameroon); Mbary Siolo Mada Bebelou (Central African Republic); Mahamat Iiss Djaskano (Chad); Shaosen Zhang and Yang Man Ni (China); Pablo Enrique, Chaparro Narvez and Nohora Gonzalez (Colombia); Astaeva Marina (Comoros); Youndouka Jean Mermoz (Congo); Jos Luis F. Garcs (Costa Rica); Tanoh Ma Antoine, Vlhi Nzi Annick Eloi, Ehui Anicet and Parfait Katche (Cte dIvoire); Kim Yun Chol and Shusil Pant (Democratic Peoples Republic of Korea); Joris Losimba Likwela (Democratic Republic of the Congo); Abdoulkader Mohamed Garad and Farah Mohamoud Ahmed (Djibouti); Jose Manuel Puello Montero (Dominican Republic); Enrique Castro Saavedra (Ecuador); Oscar Sorto Rubio (El Salvador); Matilde A. Riloha Rivas (Equatorial Guinea); Selam Mihreteab (Eritrea); Hiwot Solomon Taese (Ethiopia); Vanessa Ardillon (French Guiana, France); Abdou Razack Saou (Gabon); Adam Jagne Sonko and Momodou Kalleh (Gambia); Merab Iosava (Georgia); Constance Bart Plange, Keziah Malm, Wahjib Mohammed, Ko Oosae and Felicia Owusu-Antwi (Ghana); Adolfo Miranda (Guatemala); Nouman Diakite (Guinea); Paulo Djata (Guinea-Bissau); Reyaud Rahman (Guyana); Darlie Antoine (Haiti); Engels Ilich Banegas Medina (Honduras); G.S. Sonal (India); Anand Joshi, Asik Surya and Elvieda Sariwati (Indonesia); Leyla Faraji and Ahmad Raeisi (Iran [Islamic Republic of ]); Muthana Ibrahim Abdul Kareem (Iraq); Rebecca Kiptui (Kenya); Nurbolot Usenbaev (Kyrgyzstan); Deyer Gopinath and Khamsouane Khamsy (Lao Peoples Democratic Republic); Oliver J. Pratt (Liberia); Andry Joeliarijaona Rakotorahalahy (Madagascar); Misheck Luhanga (Malawi); Chun Paul Soo and Mohammed azi Bin Abdul Hamid (Malaysia); Diakalia Kone (Mali); Ba Mamadou Dit Dialaw and Mohamed Lemine Ould Khary (Mauritania); Hctor Olgun Bernal (Mexico); Graa Matsinhe (Mozambique); Gawrie Nirdoshi Loku Galappaththy, Krongthong Thimasarn and Thar Tun Kyaw (Myanmar); Mwalenga Henina Nghipumbwa (Namibia); Garib Das Thakur and Prakash Ghimire (Nepal); Rolando Francisco Lopez Ampie (Nicaragua); Hadiza Jackou (Niger); Nnenna Ezeigwe (Nigeria); Muhammad Suleman Memon and Qutbuddin Kaka (Pakistan); Ral Medina (Panama); Leo Makita
vi | WORLD MALARIA REPORT 2013

and Walter Kazadi-Mulombo (Papua New Guinea); Elizabeth Ferreira, Martha Torales and Cynthia Viveros (Paraguay); Maximo Manuel Espinoza Silva (Peru); Mario Baquilod (Philippines); Lasse Vestergaard and Jeunessa Sto Nino (Philippines); Lee Dong-Woo (Republic of Korea); Rukundo Alphonse and Corine Karema (Rwanda); Herodes do Sacramento Rompo (Sao Tome and Principe); Mohammed Hassan Al-Zahrani (Saudi Arabia); Mady Ba, Alioune Badara Gueye, Mdoune Ndiop and Bacary Sambou (Senegal); Thomas K. Ansumana (Sierra Leone); Albi Bobogare, Hugo Borugo, Erick Hale and Baakai Kamoriki (Solomon Islands); Fahim Yusuf and Jamal Amran (Somalia); Devan and Moonasar (South Africa); Harriet Pasquale (South Sudan); Risintha Premaratne and S. L. Deniyage (Sri Lanka); Abd Alla Ahmed Ibrahim Mohd (Sudan); B. Jubithana (Suriname); Sicelo Kunene (Swaziland); Anna Mahendeka (United Republic of Tanzania, Mainland); Abdul-wahid H. Al-mafazy (United Republic of Tanzania, Zanzibar); Sayfuddin Karimov (Tajikistan); Prayuth Sudathip (Thailand); Manel Yapabandara, Maria Mota and Maria do Rosario de Fatima Mota (Timor-Leste); Tchassama Tchadjobo (Togo); Maria Cristina Proli, Mehmet Kontas and Seher Topluoglu (Turkey); Peter Okui (Uganda); Inna Tyo, Svetlana Tsay and Natalya Lebedeva (Uzbekistan); Wesley Donald (Vanuatu); Jean-Olivier Guintran and Seyha Ros (Vanuatu); Nuncio Nelson Pizzo (Venezuela [Bolivarian Republic of ]); Dai Tran Cong and Nguyen Quy Anh (Viet Nam); Adel Nasser Aljasari and Moamer Badi (Yemen); Sabine Henry and Betty Zumbo (Mayotte); Pags Frdric (France [Runion]); Freddie Masaninga, Ingwe Masaninga and Mercy Mwanza (Zambia); Wonder Sithole (Zimbabwe). The following WHO sta in regional and subregional oces assisted in the design of data collection forms; the collection and validation of data; and the review of epidemiological estimates, country proles, regional proles and chapters: Boniface Ekoue Kinvi, Etienne Magloire Minkoulou, Georges Alfred Ki-Zerbo and Issa Sanou (WHO Regional Oce for Africa [AFRO]); Spes Ntabangana (AFRO/Inter-country Support Team [IST] Central Africa); Khoti Gausi (AFRO/IST East and Southern Africa); Abderrahmane Kharchi (AFRO/IST West Africa); Keith Carter, Rainier Escalada, Maria Paz Ade and Prabhjot Singh (WHO Regional Oce for the Americas [AMRO]); Amir Aman, Hoda Atta and Ghasem Zamani (WHO Regional Oce for the Eastern Mediterranean [EMRO]); Mikhail Ejov, Elkhan Gasimov and Karen Taksoe-Vester (WHO Regional Oce for Europe [EURO]); Leonard Icutanim Ortega and Rakesh Rastogi (WHO Regional Oce for South-East Asia[SEARO]); Eva-Maria Christophel, Bayo Fatunmbi and Raymond Mendoza (WHO Regional Oce for the Western Pacic[WPRO]). Dejan Loncar (Global Fund) assisted in the preparation of Chapter 3 (on nancing), and David Pigott (Malaria Atlas Project, University of Oxford) shared data and guidance on its use. Silas Holland, Jurate Juskaite and Melisse Murray (Global Fund) supplied information on nancial disbursements from the Global Fund and the Aordable Medicines Facility for Malaria.

For Chapter 4 (on vector control), Abraham Flaxman (Institute for Health Metrics and Evaluation) produced estimates of insecticide-treated mosquito net (ITN) coverage for African countries using data from household surveys, ITN deliveries by manufacturers, ITNs distributed by national malaria control programmes (NMCPs), and ITN coverage indicators. John Milliner (Milliner Global Associates) provided information on long-lasting insecticidal nets (LLINs) delivered by manufacturers. Katherine Theiss-Nyland (London School of Hygiene and Tropical Medicine) assessed distribution of ITNs through dierent channels. Erica Kufa helped to prepare data on intervention coverage. For chapter 6 (on malaria diagnosis and treatment), Adam Bennett and Thom Eisele (Tulane University) produced estimates of malaria treatment from household surveys. For Chapter 7, Liliana Carvajal and Holly Newby (United Nations Childrens Fund), and Lia Florey (DHS MEASURE) assisted in compiling an inventory of household surveys. For Chapter 8, Ros Howes (Malaria Atlas Project, University of Oxford), Nick Ansty (Menzies School of Health Research, Darwin) and Kevin Baird (Eijkman-Oxford Clinical Research Unit, Jakarata) assisted in the preparation of boxes on Plasmodium vivax. Li Liu (Johns Hopkins Bloomberg School of Public Health), Dan Hogan and Colin Mathers (Department of Health Statistics and Information Systems ,WHO) prepared malaria mortality estimates in children under 5 years of age on behalf of the Child Health Epidemiology Reference Group. Maps of parasite prevalence for the WHO African Region were produced by Peter Gething, Simon Hay, Andrew Henry and Catherine Moyes of the Malaria Atlas Project at the University of Oxford, with the support of the Wellcome Trust, and with assistance from Caroline Kabaria, Abdisalan Noor and Robert Snow of the Malaria Atlas Project (Africa). Paprika (Annecy, France) produced map layouts. Soce Fall (WHO Mali) provided helpful comments on Chapters 4 and 5. We are also grateful to: Larry Slutsker (Centers for Disease Control and Prevention) and Melanie Renshaw (African Leaders Malaria Alliance) who graciously reviewed all chapters and provided substantial comments for their formulation; Yehenew Walilegne (WHO) for legal review; Renata Cabrera and Bndicte Guery-Morand for the translation of the foreword, summary and key points; Mar Velarde Rodrguez (ISGlobal) for reviewing chapters and providing programmatic support for overall management of the project; Claude Cardot and the Designisgood team for the design and layout of the report; and Hilary Cadman and the Cadman Editing Services team for technical editing of the report. The World malaria report 2013 was produced by Kathryn Andrews, Maru Aregawi, Richard Cibulskis, Cristin Fergus, Michael

Lynch, Robert Newman, Zsoa Szilagyi and Ryan Williams on behalf of the WHO Global Malaria Programme. We are grateful to our colleagues in the Global Malaria Programme who also contributed to the production of chapters: Amy Barrette, Andrea Bosman, Jane Cunningham, Michael MacDonald, Rossitza Mintcheva, Abraham Mnzava, Peter Olumese, Franco Pagnoni, Charlotte Rasmussen, Aafje Rietveld, Pascal Ringwald, Vasee Sathiyamoorthy and Silvia Schwarte. We also thank Simone Colairo-Valerio, Anne Damnon and Eva Kakyomya for administrative support. Funding for the production of this report was gratefully received from the Government of Japan, the Norwegian Agency for Development Cooperation and the United Kingdom Department for International Development. We also thank the Government of Monaco for its program on Accelerated Malaria Control towards Pre-elimination in East and Southern Africa by 2015, which supported collection of malaria programme data

WORLD MALARIA REPORT 2013 | vii

Abbreviations
ABER ACD ACT AIDS AL ALMA AMFm AMP ANC ANVR API AQ AT ARDS AusAID CDC CFR CHAI CIDA CS DDT DFID annual blood examination rate active case detection artemisinin-based combination therapy acquired immunodeciency syndrome artemether-lumefantrine African Leaders Malaria Alliance Aordable Medicine Facilitymalaria Alliance for Malaria Prevention antenatal care Africa Network for Vector Resistance annual parasite index amodiaquine atovaquone acute respiratory distress syndrome Australian Agency for International Development US Centers for Disease Control and Prevention case fatality rate Clinton Health Access Initiative Canadian International Development Agency circumsporozoite dichloro-diphenyl-trichloroethane The United Kingdom Department for International Development DHS demographic and health survey DIPI domestic investment priority index DTP diphtheriatetanuspertussis E8 Elimination Eight EPI Expanded Programme on Immunization ERAR Emergency response to artemisinin resistance in the Greater Mekong subregion ERG expert review group (but evidence review group in 2013 report) FIND Foundation for Innovative New Diagnostics G6PD glucose-6-phosphate dehydrogenase Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria GMAP Global Malaria Action Plan GMP Global Malaria Programme, WHO GNI gross national income GPARC Global Plan for Artemisinin Resistance Containment GPIRM Global Plan for Insecticide Resistance GSK GlaxoSmithKline HIV human immunodeciency virus HMIS health management information system iCCM integrated community case management IEC information, education and communication IHME Institute for Health Metrics and Evaluation IM intramuscular IPT intermittent preventive treatment IPTc intermittent preventive treatment for children IPTi intermittent preventive treatment in infants IPTp intermittent preventive treatment in pregnancy IQR interquartile range IRS indoor residual spraying ISGlobal Barcelona Institute for Global Health
viii | WORLD MALARIA REPORT 2013

ITN LLIN MAP MDG MERG MICS MIS MPAC MVI NGO NMCP OECD P. PATH PCD PMI QA RAM RBM RDT SAGE SMC SP SPR TDR TEG UNAIDS UNDP UNICEF UNSE USAID VCAG WER WHA WHO WHOPES

insecticide-treated mosquito net long-lasting insecticidal net Malaria Atlas Project Millennium Development Goal RBM Monitoring and Evaluation Reference Group multiple indicator cluster survey malaria indicator survey Malaria Policy Advisory Committee Malaria Vaccine Initiative, PATH nongovernmental organization National malaria control programme Organisation for Economic Co-operation and Development Plasmodium Program for Appropriate Technology in Health passive case detection The United States Presidents Malaria Initiative quality assurance Rotarians Against Malaria Roll Back Malaria rapid diagnostic test WHO Strategic Advisory Group of Experts on Immunization seasonal malaria chemoprevention sulfadoxine-pyrimethamine slide positivity rate Special Programme for Research and Training in Tropical Diseases technical expert group Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Childrens Fund Oce of the United Nations Special Envoy for Malaria United States Agency for International Development Vector Control Advisory Group WHO Weekly Epidemiological Record World Health Assembly World Health Organization WHO Pesticide Evaluation Scheme

Abbreviations of WHO Regions / Oces AFR WHO African Region AFRO WHO Regional Oce for Africa AMR WHO Region of the Americas AMRO WHO Regional Oce for the Americas EMR WHO Eastern Mediterranean Region EMRO WHO Regional Oce for the Eastern Mediterranean EUR WHO European Region EURO WHO Regional Oce for Europe SEAR WHO South-East Asia Region SEARO WHO Regional Oce for South-East Asia WPR WHO Western Pacic Region WPRO WHO Regional Oce for the Western Pacic

Summary and Key Points

The World Malaria Report 2013 summarizes information received from malaria-endemic countries and other sources, and updates the analyses presented in the 2012 report. It highlights the progress made towards the global malaria targets set for 2015, and describes current challenges for global malaria control and elimination. Since 2000, a tremendous expansion in the nancing and coverage of malaria control programmes has led to a wide-scale reduction in malaria incidence and mortality. Based on reported data, 59 out of 103 countries that had ongoing malaria transmission in 2000 are meeting the Millennium Development Goal (MDG) target of reversing the incidence of malaria. Of these, 52 are on track to meet Roll Back Malaria (RBM) and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015, including 8 countries of the WHO African Region. In 41 countries it is not possible to assess trends using reported data because of inconsistencies in the completeness of reporting over time, changes in diagnostic practice or health-service use. For these countries, which accounted for 80% of cases in 2000, inferences about malaria trends need to be based on estimates of the malaria case incidence and mortality rates. Worldwide, between 2000 and 2012, estimated malaria mortality rates fell by 45% in all age groups and by 51% in children under 5 years of age. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates are projected to decrease by 56% in all ages, and by 63% in children under 5 years of age by 2015; this represents substantial progress towards the World Health Assembly target of reducing malaria mortality rates by 75% by 2015. Modelling suggests that an estimated 3.3 million malaria deaths were averted between 2001 and 2012, and that 69% of these lives saved were in the 10 countries with the highest malaria burden in 2000; thus, progress is being made where it matters most. About 3 million (90%) of the deaths averted between 2001 and 2012 are estimated to be in children under 5 years of age in sub-Saharan Africa. These account for 20% of the 15 million child deaths that are estimated to have been averted in subSaharan Africa since 2000 through overall reductions in child mortality rates. Thus, decreases in malaria deaths have contributed substantially to progress towards achieving the target for MDG 4, which is to reduce, by two thirds, the under-5 mortality rate between 1990 and 2015. Nevertheless, between 2011 and 2012, the pace of decrease in estimated malaria mortality rates slowed. This slowing is partly because the model that is used to estimate malaria deaths in children under 5 years of age in Africa uses insecticide-treated mosquito net (ITN) coverage as an input, and ITN coverage attened in 20112012 following decreases in funding for malaria control in 2011. In 2012, nancing of malaria programmes was estimated to be less than half of the estimated US$ 5.1 billion required globally. Thus, millions of people at risk of malaria still do not have access to interventions such as an ITN, indoor residual spraying (IRS), diagnostic testing and artemisinin-based combination therapies (ACTs). As a result, an estimated 207 million cases (uncertainty interval, 135287 million) and 627 000 malaria deaths (uncertainty interval, 473 000789 000) are estimated to have occurred in 2012. There is an urgent need to increase funding for malaria control and to expand programme coverage, in order to meet international targets for reducing malaria cases and deaths.

Policy development
Several new and updated malaria control policies, operational manuals, plans and initiatives were released in 2013, following meetings of WHOs Malaria Policy Advisory Committee (MPAC). 1. The MPAC, which came into operation in 2012, continued its work in 2013; its mandate is to provide strategic advice and technical input to WHO on all aspects of malaria control and elimination. In accordance with the MPAC recommendations, WHO issued guidance on a range of policy areas, including achieving universal coverage with long-lasting insecticidal nets (LLINs), estimating the longevity of LLINs, and capacitybuilding in malaria entomology and vector control. 2. Other WHO guidance published in 2013 includes (i) an operational manual for IRS; (ii) an operational manual for larval source management; (iii) test procedures for insecticide resistance monitoring in malaria vector mosquitoes; (iv) a eld guide on seasonal malaria chemoprevention (SMC); (v) a handbook on the management of severe malaria; (vi) a framework for action to respond to artemisinin resistance in the Greater Mekong subregion; (vii) a eld handbook on malaria control in complex emergencies (developed in conjunction with several partner agencies); and (viii) three training manuals.

Financing malaria control

The total international and domestic funding committed to malaria control was estimated to be US$ 2.5 billion in 2012 substantially less than the amount that will be needed to reach the global targets. 3. International disbursements to malaria-endemic countries have increased markedly, from less than US$ 100 million in 2000 to US$ 1.6 billion in 2011, and an estimated US$ 1.94 billion in 2012 and 1.97 billion in 2013. However, increases in international funding have slowed in recent years, to an average of 4% per year between 2009 and 2013, compared to an average of 43% per year between 2005 and 2009. 4. Reported data suggest that global domestic nancing for malaria increased over the period 20052012, from US$ 436 million in 2005 to US$ 522 million in 2012. It is estimated that domestic government malaria spending rose at a rate of 4% per year between 2005 and 2012.
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5. Global resource requirements for malaria control were estimated in the 2008 RBM Global Malaria Action Plan (GMAP) to exceed US$ 5.1 billion per year between 2011 and 2020. Combining both domestic and international funds, the resources available for malaria control globally were estimated to be US$ 2.5 billion in 2012, leaving a gap of US$ 2.6 billion. Projections of both domestic and international resources available between 2013 and 2016 indicate that total funding for malaria control will reach approximately US$ 2.85 billion between 2014 and 2016, which is substantially below the amount required to achieve universal access to malaria interventions. 6. International investments in malaria control have been targeted to countries with higher mortality rates and lower national incomes, particularly those in Africa. However, domestic government investments are highest in wealthier countries and lowest in countries with the highest malaria mortality rates. The low rates of domestic spending in countries with higher disease burdens is principally because these countries have lower national incomes per capita. 7. There is variation in the priority given to malaria control by domestic governments that have similar levels of resource availability. Countries that display greater commitment as measured by a domestic investment priority index showed greater success in reducing malaria case incidence between 2000 and 2012 than did other countries.

households and access to an ITN for every person at risk of malaria. 10. The percentage of households owning at least one ITN in sub-Saharan Africa is estimated to have risen from 3% in 2000 to 56% in 2012, but declined slightly to 54% in 2013. The proportion of the population with access to an ITN in their household increased during the same period, reaching 42% in 2013. The proportion of the population sleeping under an ITN which represents the population directly protected was estimated to be 36% in 2013. 11. A comparison of the proportion of the population with access to an ITN, and the proportion sleeping under an ITN, suggests that a high percentage (86%) of the population with access to an ITN actually uses it, indicating that eorts to encourage ITN use have been successful. Lack of availability of nets is the main constraint to increasing the number of at-risk persons sleeping under an ITN. 12. Use of ITNs among vulnerable populations, pregnant women and children under 5 years of age is higher than use among the population as a whole. This indicates that these groups remain protected as countries scale up for universal ITN coverage, and it highlights the need to increase access to ITNs among all persons at risk.

Indoor residual spraying

13. IRS remains a powerful vector control tool for reducing and interrupting malaria transmission. In 2012, a total of 88 countries, including 40 in the African Region, recommended IRS for malaria control. 14. In 2012, 135 million people (4% of the global population at risk of malaria) were protected by IRS worldwide. In the African Region, the proportion of the population at risk that was protected rose from less than 5% in 2005 to 11% in 2010, but fell to 8% in 2012, with 58 million people beneting from the intervention. The decrease in the number of people protected by IRS in Africa appears to be partly due to increased use of more costly non-pyrethroid insecticides (in response to the threat of insecticide resistance) in a setting of limited IRS budgets. The use of non-pyrethroids for IRS may become increasingly important as a resistancemanagement tool because all currently approved LLINs are pyrethroid based.

Progress in vector control

In sub-Saharan Africa, the proportion of the population with access to an ITN in their household increased dramatically from 2005 to 2011 but the rate attened during the last 2 years, reaching 42% in 2013. Increased deliveries of ITNs during the next 2 years should increase ITN coverage.

Insecticide-treated mosquito nets

8. By 2012, 34 countries in the African Region and 83 countries worldwide had adopted the WHO recommendation to provide ITNs to all persons at risk for malaria. A total of 88 countries, including 39 in Africa, distribute ITNs free of charge. 9. Every year, at least 150 million ITNs are needed to maintain a supply of 450 million ITNs in households over each 3-year period and protect all populations at risk of malaria in subSaharan Africa. Between 2004 and 2010, the number of ITNs delivered annually by manufacturers to malaria-endemic countries in sub-Saharan Africa increased from 6 million to 145 million. However, only 92 million ITNs were delivered by manufacturers in 2011, and only 70 million were delivered in 2012. The estimated numbers of ITNs delivered in 2013 (136 million) and nanced by donors for 2014 (approximately 200 million) are close to the number of ITNs required annually to protect all populations at risk. However, even with the increase in yearly deliveries, the projected 3-year total of ITNs delivered in 20122014 (about 400 million) will still be below the minimum number needed to protect all persons at risk of malaria. The appropriate levels of ITN deliveries need to be maintained each year, to ensure the availability of ITNs in
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Insecticide resistance
15. Mosquito resistance to at least one insecticide used for malaria control has been identied in at least 64 malaria-endemic countries worldwide. In May 2012, WHO and RBM released the Global Plan for Insecticide Resistance Management (GPIRM) in malaria vectors; the GPIRM is a ve-pillar strategy for managing the threat of insecticide resistance. Stakeholders in the global malaria community have begun activities related to implementing the strategy laid out in the GPIRM. 16. Monitoring insecticide resistance is a necessary element of the implementation of insecticide-based vector control interventions. In 2012, a total of 58 countries reported that they had adopted a policy of routine monitoring of insecticide resistance.

Progress on chemoprevention
Among African countries reporting this information to WHO, the median percentage of pregnant women attending antenatal care (ANC) who received at least one dose of intermittent preventive treatment (IPT) during pregnancy in 2012 was 64%, whereas 38% received at least two doses and 23% received at least three doses, indicating that there is considerable scope for improving protection for pregnant women. 17. In sub-Saharan Africa, an estimated 35 million pregnant women and a large portion of the estimated 26 million infants born each year would benet from IPT. In addition, about 25 million children in the Sahel subregion of Africa could be protected from malaria through SMC. 18. A total of 36 sub-Saharan African countries with moderate to high malaria transmission had adopted IPT for pregnant women (IPTp) as national policy by the end of 2012. This policy was also adopted by Papua New Guinea (in the Western Pacic Region) in 2009. 19. Among 26 of the 36 moderate to high transmission countries in the African Region that have adopted IPTp as national policy and for which data are available a median of 64% of pregnant women attending ANC received at least one dose of IPTp in 2012, 38% received at least two doses and 23% received at least three doses. In 13 countries in the African Region for which household survey data were available for 20102012, the weighted average of all pregnant women who received one dose of IPTp during pregnancy was 37%, whereas 23% received two doses and 8% received three doses. 20. Since October 2012, WHO has recommended that IPTp be given at each scheduled antenatal visit after the rst trimester. Analysis of household survey data reveals that the proportion of pregnant women who receive IPTp is well below the proportion who attend ANC. The estimated proportion of ANC visits in which IPTp could be given but is not is high, at 72%. A lower proportion of women receive IPTp during ANC visits than receive tetanus toxoid (another key component of ANC). This indicates that the capacity to deliver preventive services during ANC visits is high, and that barriers to IPTp can be overcome. 21. All infants at risk of Plasmodium falciparum infection in sub-Saharan African countries with moderate-to-high malaria transmission and low levels of parasite resistance to the recommended agent sulfadoxine-pyrimethamine (SP) should receive preventive malaria treatment through immunization services at dened intervals that correspond to routine vaccination schedules. Only one country, Burkina Faso, has adopted a national policy of IPT for infants (IPTi) since the WHO recommendation was issued in 2009. 22. In March 2012, WHO issued a recommendation on SMC for children aged 359 months, and in August 2013, WHO released a eld guide for implementation of SMC. Two endemic countries have adopted SMC, and several countries involved in evaluating the policy have indicated that they plan to adopt this policy and expand SMC coverage beyond their study populations.

Progress in diagnostic testing and malaria treatment

The numbers of procured rapid diagnostic tests (RDTs) and ACTs are increasing, as is the reported rate of diagnostic testing in the public sector in the African Region, which increased from 37% in 2010 to 61% in 2012. As a result, there has been a decrease in the number of suspected malaria cases treated presumptively with antimalarial drugs. However, millions of people with suspected malaria still do not receive a diagnostic test, and many people with conrmed infections do not receive appropriate treatment with a quality assured antimalarial.

Diagnostic testing
23. Implementation of universal diagnostic testing in the public and private sectors would substantially reduce the global requirements for antimalarial treatment. In 2012, 41 of 44 countries with ongoing malaria transmission in the African Region, and 49 of 55 countries in other WHO regions, reported having adopted a policy of providing parasitological diagnosis for all age groups. This represents an increase of 6 countries in the African Region since 2009. 24. Malaria diagnostic testing is provided free of charge in the public sector in 85 countries around the world. From 2010 to 2012, the proportion of suspected malaria cases receiving a diagnostic test in the public sector increased from 37% to 61% in the African Region, and from 44% to 64% globally. Most of the increase in testing in the African Region is attributable to increased use of RDTs, which accounted for 40% of all cases tested in the region in 2012. 25. The number of patients tested by microscopic examination increased to a peak of 188 million in 2012, with India accounting for over 120 million blood-slide examinations. The number of RDTs supplied by manufacturers increased from 88 million in 2010 to 205 million in 2012. This included increased sales for both P. falciparum-specic tests and combination tests that can detect more than one parasite species. 26. A total of 48 countries reported deployment of RDTs at the community level, and 15 million patients were reported as having been tested through such programmes in 2012. Household survey data from 14 countries collected during 20102012 suggest that diagnostic testing is not as widely available in the private sector as it is in the public sector. 27. RDTs are increasingly used for diagnostic testing of suspected malaria cases in health facilities, including for the diagnosis of P. vivax. Among 42 countries reporting the type of RDTs used, 15 reported deploying RDTs that could detect P. vivax specically. In these countries, the proportion of P. vivax cases conrmed by RDT (rather than microscopy) was similar to the proportion of P. falciparum cases conrmed by RDT.

Treatment
28. ACTs are recommended as the rst-line treatment of malaria caused by P. falciparum, the most dangerous of the Plasmodium parasites that infect humans. By 2012, 79 countries and territories had adopted ACTs as rst-line treatment
WORLD MALARIA REPORT 2013 | xi

for P. falciparum malaria. P. vivax malaria should be treated with chloroquine where that drug is eective, or by an appropriate ACT in areas where P. vivax is resistant to chloroquine. Treatment of P. vivax should be combined with a 14-day course of primaquine to prevent relapse. 29. From reports of manufacturers and the Aordable Medicines Facility-malaria (AMFm) initiative, the number of ACT treatment courses delivered to the public and private sectors increased from 11 million globally in 2005 to 76 million in 2006, and reached 331 million in 2012. The increases in ACT procurement in routine public sector in 2012 were due primarily to an increase of about 50% in public sector deliveries between 2011 to 2012. Drugs procured for the public and private sector through the AMFm initiative which is now in a transitional phase towards eventual integration into the routine grant-making process for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) decreased slightly from 156 million treatment courses in 2011 to 150 million in 2012. 30. It has been dicult to track the extent to which patients with conrmed malaria received antimalarial medicines, because information linking diagnostic testing and treatment has been limited in both household surveys and routine healthinformation systems. An estimate of the proportion of patients in the public sector potentially treated with ACTs (rather than a less eective antimalarial) can be made by comparing the number of ACT treatments distributed by national malaria control programmes (NMCPs) with the number of presumed (i.e. treated without testing) and conrmed (i.e. conrmed by microscopy or RDT) cases of P. falciparum malaria (adjusted for reporting completeness or estimated, in situations where reported data are lacking). This proportion varies by WHO region, but has increased over time in the African Region, where it reached 60% in 2012. 31. In nine countries in the African Region with more than one household survey between 2006 and 2012, the proportion of febrile children given antimalarial treatment comprising ACTs increased over time, in both the public and private sectors. In the most recent surveys, the median proportion of children receiving an antimalarial who received an ACT was 68%; however, because a substantial portion of children are not brought for care of fever, and not all children with suspected malaria are given a diagnostic test, the proportion of all children with malaria who receive an ACT is likely to be substantially lower. In an analysis of 26 household surveys conducted in 20102012 that used a positive RDT among febrile children as a proxy for conrmed malaria, the mean proportion of all children with conrmed malaria who received an ACT was 16% (range, 1%42%). Increased access to care for fever, as well as appropriate diagnostic testing and therapeutic management at all places of care, is needed to ensure that all patients with malaria receive prompt and eective treatment. 32. In the African Region in 2012, the total number of tests (both microscopy and RDTs) was almost equal to the number of ACTs distributed by NMCPs an increased ratio compared to previous years. However, in most malaria-endemic areas,
xii | WORLD MALARIA REPORT 2013

the ratio is expected to exceed 2, because less than half of suspected malaria cases will have conrmed malaria and require treatment with an ACT.

Antimalarial drug resistance

33. WHO recommends that oral artemisinin-based monotherapies be progressively withdrawn from the market and replaced with ACTs a policy that was endorsed by the World Health Assembly in 2007. The number of countries that still allow the marketing of these products decreased from 55 in 2008 to 9 as of November 2013; 6 of those 9 countries are in the African Region. The number of pharmaceutical companies marketing these products dropped from 38 in 2010 to 30 in 2013. Most of the countries that allow marketing of these medicines are in the African Region, whereas most of the manufacturers are in India. 34. Therapeutic ecacy studies remain the gold standard for guiding drug policy; such studies should be undertaken every 2 years. In 2011 and 2012, studies of rst- or secondline antimalarial treatments were completed in 48 of 67 (72%) countries where P. falciparum ecacy studies were possible an increase from 31 of 75 (41%) countries during 20082009. (In 32 countries with ongoing malaria transmission, ecacy studies are currently impracticable because of low malaria incidence, or because the countries are endemic for P. vivax only.) 35. Parasite resistance to artemisinins has now been detected in four countries of the Greater Mekong subregion: Cambodia, Myanmar, Thailand and Viet Nam. Despite the observed changes in parasite sensitivity to artemisinins, ACTs continue to cure patients, provided that the partner drug is still ecacious. In Cambodias Pailin province, resistance has been found to both of the components of multiple ACTs; therefore, special provisions for directly observed therapy using a non-artemisinin-based combination (atovaquone + proguanil) have been introduced. In April 2013, WHO released the Emergency response to artemisinin resistance in the Greater Mekong subregion: Regional framework for action 20132015. The document describes priority areas in which action is needed in the coming years to contain artemisinin resistance.

Malaria surveillance, monitoring and evaluation

In 2012, in 62 countries of 103 that had ongoing malaria transmission in 2000, reporting was considered to be suciently consistent to make a reliable judgement about malaria trends for 20002012. In the 41 remaining countries, which account for 80% of estimated cases, it is not possible to reliably assess malaria trends using the data submitted to WHO. Information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest. 36. In 2012, routine health information systems detected only 14% of the cases estimated to occur globally. Case detection rates were lowest in countries with the highest numbers of malaria cases. Similarly, the proportion of deaths that are

reported was lowest in countries with the greatest number of malaria deaths. Surveillance systems do not need to detect all cases in order to reliably assess trends; however, case detection eorts do need to be reasonably uniform over time. Countries with fewer estimated cases of malaria appear to be most able to assess trends in incidence. In the 41 countries that account for 80% of estimated cases in 2000, it is not possible to reliably assess malaria trends 20002012 using the data submitted to WHO. Thus, information systems are weakest where the malaria burden is greatest. 37. In contrast to routinely reported data, household surveys are more commonly undertaken in countries with the highest number of malaria cases. Fifty countries, of which 34 were in the African Region, had at least one household survey over the 3-year period 20112013. Indicators most commonly measured were those on the availability of ITNs and the use of antimalarial medicines. Only 25% of surveys included questions on fever cases receiving a nger stick or heel prick, whereas 90% enquired about malaria treatment a nding that will need to change if progress towards universal diagnostic testing is to be tracked. The number of surveys that measure parasite prevalence has increased since 2005, rising to 81% of all surveys conducted between 2011 and 2013.

41. Of 97 countries with ongoing transmission in 2013, 12 are classied as being in the pre-elimination phase of malaria control, and 7 as being in the elimination phase. A further 7 countries are classied as being in the prevention of introduction phase. In 2012, the European Region reported only 255 indigenous cases; hence, it is close to attaining the goal of eliminating malaria from the region by 2015, as set out in the 2005 Tashkent Declaration. Nonetheless, recent outbreaks in Greece and Turkey highlight the continual threat of reintroduction, and the need for continued vigilance to ensure that any resurgence is rapidly contained. 42. The 52 countries that are projected (based on reported data) to decrease malaria incidence by 75% by 2015 accounted for only 8 million (4%) of the total estimated cases of 226 million in 2000. This is partly because progress has been faster in countries with lower numbers of cases, but is also inuenced by the poorer quality of surveillance data submitted by countries with larger numbers of cases. Improved surveillance and evaluation in countries with higher malaria burdens is essential for the impact of malaria investments to be properly assessed. 43. Because countries with higher numbers of cases are less likely to submit suciently consistent data for assessing trends, it is necessary to draw inferences about trends in these countries using estimated numbers of cases rather than surveillance data. There were an estimated 207 million cases of malaria worldwide in 2012 (uncertainty interval, 135287 million). Most of the estimated cases (80%) occur in sub-Saharan Africa. About 9% of estimated cases globally are due to P. vivax, although the proportion outside the African continent is 50%. The estimated incidence of malaria fell by 29% globally between 2000 and 2012, and by 31% in the African Region. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria case incidence is projected to decrease by 36% globally by 2015, and by 40% in the African Region. 44. There were an estimated 627 000 malaria deaths worldwide in 2012 (uncertainty interval, 473 000789 000). Of the estimated deaths, most occur in sub-Saharan Africa (90%) and in children under 5 years of age (77%). Between 2000 and 2012, estimated malaria mortality rates decreased by 45% worldwide and by 49% in the African Region; they are estimated to have decreased by 51% in children under 5 years of age globally and by 54% in the African Region. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates are projected to decrease by 56% globally and by 62% in the African Region by 2015. In children under 5 years of age, they are projected to decrease by 63% globally and by 68% in the African Region by 2015. 45. The pace of decrease in estimated malaria mortality rates accelerated from 2005, but slowed between 2011 and 2012. This slowing is partly because the model that is used to estimate malaria deaths in children under 5 years of age in Africa uses ITN coverage to adjust the proportion of all deaths that are attributed to malaria, and ITN coverage attened in 20112012 following decreases in funding for malaria control in 2011.
WORLD MALARIA REPORT 2013 | xiii

Impact of malaria control

Since 2000, more than half of the countries that had ongoing malaria transmission in 2000 have recorded decreases in the incidence of conrmed malaria, or in reported admissions and deaths (or both). Estimated malaria mortality rates worldwide fell by 45% between 2000 and 2012 in all age groups, and by 51% in children under 5 years of age. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates are projected to decrease by 56% in all ages, and by 63% in children under 5 years of age, by 2015. 38. An estimated 3.4 billion people were at risk of malaria in 2012. Of this total, 2.2 billion were at low risk (<1 reported case per 1000 population), of whom 94% were living in geographic regions other than the African Region. The 1.2 billion at high risk (>1 case per 1000 population) were living mostly in the African Region (47%) and the South-East Asia Region (37%). 39. Based on reported data, 59 out of 103 countries that had ongoing malaria transmission in 2000 are meeting the MDG target of reversing the incidence of malaria. Of these, 52 are on track to meet RBM and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015, including 8 countries of the African Region. 40. Decreases in the incidence of P. falciparum are, on average, larger than those of P. vivax, suggesting that P. vivax responds more slowly to control measures, possibly because of its biological characteristics. As a result, many NMCPs need to give greater attention to the control of P. vivax as they near elimination, particularly in areas outside sub-Saharan Africa. In countries where both species are transmitted, P. vivax predominates in countries that are in the pre-elimination and elimination phases.

46. More than 80% of estimated malaria deaths in 2012 occur in just 17 countries, and 80% of cases occur in 18 countries, with the Democratic Republic of the Congo and Nigeria together accounting for 40% of the estimated global total. Targets for reduction of cases and deaths will not be attained unless substantial progress can be made in countries that account for the vast majority of the malaria burden. 47. Four countries account for more than 80% of estimated cases of P. vivax cases (Ethiopia, India, Indonesia and Pakistan). P. vivax infection has been associated with severe malaria and death, although the risks of severe disease and case fatality rates for P. vivax infection have not been rmly established. The presence of comorbidities in particular, concomitant malnutrition is suspected to increase the risk of severe disease in P. vivax infection, although this risk also remains poorly dened. Further study is required to rene existing knowledge of the spectrum of severe P. vivax malaria, and the risks of severe disease and death with this infection. 48. Progress in reducing malaria case incidence and mortality rates has been faster in countries with lower numbers of cases and deaths in 2000. However, the vast majority of numbers of cases and deaths averted between 2000 and 2012 have been in countries that had the highest malaria burdens in 2000. If the malaria incidence and mortality rates in 2000 had remained unchanged over the decade, 500 million more cases and 3.3 million deaths would have occurred between 2001 and 2012. Most of the malaria cases averted (67%) and lives saved (93%) have been in the African Region. 49. Of the 3.3 million deaths averted between 2001 and 2012, 3 million (90%) are estimated to be in children under 5 years of age in sub-Saharan Africa. They account for 20% of the 15 million child deaths that are estimated to have been averted in sub-Saharan Africa since 2000 through overall reductions in child mortality rates. Thus, decreases in malaria deaths have contributed substantially to progress towards achieving the target for MDG 4 of reducing, by two thirds, the under-5 mortality rate between 1990 and 2015.

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Avant-propos
Dr Margaret Chan Directeur Gnral de lOrganisation mondiale de la Sant (OMS)
Cette anne, le Rapport sur le paludisme dans le monde fait tat de lavance remarquable de la lutte mondiale contre le paludisme, et prsente les estimations du poids de la maladie mises jour pour la priode 2000-2012. Le rapport rvle que les engagements politiques accrus et laugmentation des investissements mondiaux en faveur de la lutte antipaludique depuis 2000 ont conduit des avances majeures en la matire, lorigine de 3,3 millions de vies sauves selon les estimations. Chaque anne, nos connaissances sur les tendances du paludisme et sur le fardeau de la maladie dans le monde samliorent, comparativement la situation qui prvalait en 2000. Selon les estimations les plus rcentes, les taux de mortalit imputables au paludisme ont t rduits denviron 45 % dans le monde et de 49 % dans la Rgion africaine de lOMS entre 2000 et 2012. Au cours de la mme priode, les taux dincidence du paludisme ont diminu de 29 % au niveau mondial et de 31 % dans la Rgion Afrique. Ces rductions importantes sont le rsultat dune intensication majeure des interventions de lutte antivectorielle, de lutilisation des tests diagnostiques et des traitements par une combinaison thrapeutique base dartmisinine ou CTA. Mais cette avance ne permet pas de cder lautosatisfaction. Les chires absolus des cas de paludisme et de dcs ne diminuent pas aussi rapidement quils le pourraient. La maladie a encore emport 627 000 vies en 2012 selon les estimations, principalement des enfants de moins de cinq ans en Afrique. Cela correspond 1 300 vies de jeunes enfants perdues chaque jour cause du paludisme, un rappel fort indiquant que la victoire sur cet ennemi de longue date nest pas pour demain. Le fait que tant de personnes meurent de piqres de moustiques est lune des plus grandes tragdies du XXIe sicle. Si les engagements politiques sessouent, les progrs majeurs qui ont t raliss pourraient tre anantis en une seule saison de transmission dans certaines zones. Au cours de ces dernires annes, nous avons commenc constater les premiers signes dun possible ralentissement. En 2011 et 2012, la livraison de moustiquaires imprgnes dinsecticide de longue dure aux pays dendmie palustre sest ralentie et les programmes de pulvrisations intradomiciliaires dinsecticides eet rmanent ont stagn. Pendant cette mme priode, les taux de mortalit dus au paludisme ont continu diminuer, mais un rythme plus lent. En 2013, les livraisons de moustiquaires ont nouveau augment, et celles prvues lanne prochaine sont encore suprieures. Toutefois, des eorts encore plus importants devront tre consentis pour protger toutes les personnes risque. Alors que la communaut internationale avance progressivement vers le programme de dveloppement pour laprs-2015, nous ne devons par perdre de vue ce que les populations les plus vulnrables attendent de nous. Le concept de couverture sanitaire universelle reprsente la fois une valeur sociale et une approche des soins qui gnre une meilleure sant pour des populations entires, rduit les ingalits sociales et protge de la pauvret induite par les dpenses de soins de sant. Il sagit dun concept cl qui occupe dj le centre du dbat mondial sur la sant, mais aussi le centre du dbat sur le prochain ensemble dobjectifs pour le dveloppement. Les progrs raliss dans la lutte contre le paludisme sont une preuve satisfaisante des bnces tangibles de laccs des interventions vitales pour lensemble des populations. La communaut internationale doit aussi continuer se mobiliser pour combler lcart dans les nancements internationaux consacrs la prvention et la lutte antipaludiques. Les nancements actuellement disponibles sont largement insusants pour tablir laccs universel aux interventions de lutte antipaludique. Pour atteindre notre objectif, nous devons intensier les eorts visant amliorer les outils de lutte antivectorielle. Nous devons aussi garantir que les groupes les plus vulnrables, cest--dire les enfants de moins de cinq ans, les nourrissons et les femmes enceintes, ont accs aux traitements prventifs intermittents recommands par lOMS, lorsquils sont adapts. Si les progrs en matire dlargissement de lutilisation des tests diagnostiques et de traitements satisfaisants aux normes dassurance qualit ont t considrables au cours de ces dernires annes, nous sommes toutefois loin datteindre laccs universel. En outre, la rsistance parasitaire lartmisinine le composant principal des mdicaments antipaludiques les plus ecaces au monde et la rsistance des moustiques aux insecticides restent des proccupations majeures. Si elles ne sont pas prises en compte avec la diligence requise, ces dernires pourraient menacer les progrs remarquables accomplis depuis 2000. Si lOMS a publi des stratgies mondiales pour surmonter ces dicults, leur adoption par les pays est lente, principalement en raison de linsusance des nancements. En avril 2013, lors de la Journe mondiale du paludisme, lOMS a publi louvrage Emergency response to artemisinin resistance in the Greater Mekong subregion (Riposte duregence la rsistance lartmisinine dans la sous-rgion du Grand Mkong) pour orienter les pays dans lintensication et la mise en uvre des interventions visant llimination des parasites rsistants. Lcart de nancement pour cette intervention est aussi trs important. Le renforcement des infrastructures de sant, les systmes de surveillance et de notications vitales sont galement indispensables pour obtenir de nouveaux progrs. Selon les donnes soumises, 59 pays ont atteint la cible de lOMD dinverser la tendance de lincidence du paludisme, et 52 pays sont en bonne voie vers une rduction de leur taux dincidence des cas de paludisme de 75 %, dans le droit l des cibles xes pour 2015 par lAssemble mondiale de la sant et le partenariat Roll Back Malaria. Toutefois, ces 52 pays reprsentent seulement 4 % ou huit millions des cas totaux estims de paludisme dans le monde. Dans 41 pays dendmie palustre, et notamment dans les pays o le fardeau du paludisme est le plus lourd, nous ne pouvons valuer de manire able les tendances du paludisme. Un eort concert visant amliorer les systmes de surveillance est requis pour combler cet cart entre nos connaissances et la situation du paludisme. LOrganisation est reconnaissante pour lengagement des ministres de la Sant des pays endmiques et de leurs nombreux partenaires du dveloppement. Nous sommes convaincus que si nous restons dtermins et agissons avec diligence, nous pouvons vaincre ce vieil ennemi une fois pour toutes.

WORLD MALARIA REPORT 2013 | xv

Rsum et points essentiels

Le Rapport 2013 sur le paludisme dans le monde rcapitule les informations communiques par des pays dendmie palustre ainsi que des renseignements manant dautres sources. Il sattache mettre jour les analyses gurant dans le Rapport 2012. Il souligne les progrs accomplis dans le but de contribuer au respect des objectifs internationaux xs lhorizon 2015 et dcrit les ds actuels en ce qui concerne la lutte et llimination du paludisme dans le monde. Les annes coules depuis 2000 ont t marques par une augmentation considrable du nancement et de la couverture des programmes de lutte contre le paludisme. Cette situation a conduit une rduction grande chelle de lincidence du paludisme et de la mortalit. Si lon se fonde sur les donnes soumises, 59 pays sur 103 o la transmission du paludisme tait active en 2000 atteignent lObjectif du Millnaire pour le dveloppement (OMD) dinverser la tendance du paludisme. Parmi ceux-ci, 52 sont en bonne voie pour atteindre les cibles xes par lAssemble mondiale de la sant et par le partenariat Roll Back Malaria (RBM Faire reculer le paludisme ) : rduire de 75 % le nombre de cas de paludisme dici 2015, et notamment dans huit pays de la rgion Afrique. Dans 41 pays, il nest pas possible dvaluer les tendances partir des donnes soumises en raison des incohrences dans lexhaustivit des donnes dans le temps, des modications dans les pratiques diagnostiques ou le recours aux services de sant. Pour ces pays, qui reprsentaient 80 % des cas en 2000, il est ncessaire dextrapoler les tendances partir des estimations des taux dincidence des cas et de mortalit imputables au paludisme. Dans le monde, entre 2000 et 2012, les taux de mortalit estims dus au paludisme ont chut de 45 % dans toutes les tranches dge et de 51 % chez les enfants de moins de cinq ans. Si le taux annuel de diminution observ au cours des 12 dernires annes se conrme, alors les taux de mortalit imputables au paludisme pourraient diminuer de 56 % dans toutes les tranches dge, et de 63 % chez les enfants de moins de cinq ans, dici 2015. Ainsi, cela reprsente une avance importante vers la cible de lAssemble mondiale de la sant visant rduire les taux de mortalit du paludisme de 75 % dici 2015. La modlisation suggre que 3,3 millions de dcs imputables au paludisme ont t vits entre 2001 et 2012, et que 69 % de ces vies sauves se situaient dans les dix pays o la charge du paludisme tait la plus leve en 2000. Des progrs sont donc accomplis l o ils comptent le plus. Il a t estim quenviron 3 millions (90 %) des dcs vits entre 2001 et 2012 concernaient des enfants de moins de cinq ans en Afrique subsaharienne. Cela reprsente 20 % des 15 millions de dcs denfants qui ont t vits en Afrique subsaharienne depuis 2000 selon les estimations, en raison des rductions globales des taux de mortalit infantile. Par consquent, les diminutions du nombre de dcs dus au paludisme ont considrablement contribu progresser vers la ralisation de lOMD 4, qui est de rduire de deux tiers, entre 1990 et 2015, le taux de mortalit des enfants de moins de cinq ans. Cependant, entre 2011 et 2012, le rythme de diminution des taux de mortalit estims imputables au paludisme a ralenti. Ce ralentissement sexplique en partie parce que la modlisation qui
xvi | WORLD MALARIA REPORT 2013

est applique pour estimer le taux de dcs chez les enfants de moins de cinq ans en Afrique utilise les donnes de la couverture des moustiquaires imprgnes dinsecticides longue dure (MII), alors que cette couverture a stagn entre 2011 et 2012 suite aux baisses du nancement de la lutte contre le paludisme en 2011. En 2012, le nancement des programmes de lutte contre le paludisme a t estim moins de la moiti des US$ 5,1 milliards estims ncessaires au niveau mondial. Des millions de personnes risque de paludisme nont toujours pas accs aux interventions telles que les MII, les pulvrisations intradomiciliaires dinsecticides eet rmanent (PII), les tests de diagnostic et les combinaisons thrapeutiques base dartmisinine (CTA). En consquence, il a t estim quen 2012, environ 207 millions de cas (intervalle dincertitude : 135-287 millions) et 627 000 dcs (intervalle dincertitude : 473 000-789 000) taient imputables au paludisme. Il est urgent daugmenter le nancement de la lutte contre le paludisme et dlargir la couverture des interventions, pour atteindre les cibles de rduction des cas et de dcs xes lchelle internationale.

laboration de politiques
Des nouvelles politiques, des politiques actualises, des manuels oprationnels, des plans et des initiatives sur la lutte contre le paludisme ont t publis en 2013, suite aux runions du Comit de pilotage de la politique de lutte antipaludique (MPAC).
1. Le MPAC, qui est devenu oprationnel en 2012, a poursuivi sa mission en 2013 consistant fournir des conseils stratgiques et une contribution technique lOrganisation mondiale de la Sant (OMS) sur tous les aspects de la lutte contre le paludisme et son limination. Conformment aux recommandations du MPAC, lOMS a publi des recommandations sur une vaste gamme de domaines politiques, notamment latteinte de la couverture universelle des MII, lestimation de leur longvit, et le renforcement des capacits en matire dentomologie du paludisme et de la lutte antivectorielle. 2. Parmi les autres recommandations publies par lOMS en 2013, on peut citer (i) un manuel pratique pour les PII ; (ii) un manuel pratique pour la gestion des gtes larvaires ; (iii) des protocoles de test pour le suivi de la rsistance aux insecticides chez les moustiques vecteurs du paludisme ; (iv) un guide pratique sur la chimioprvention du paludisme saisonnier (CPS) ; (v) un guide pratique sur la prise en charge du paludisme grave ; (vi) un cadre dintervention pour la riposte la rsistance lartmisinine dans la sous-rgion du Grand Mkong ; (vii) un manuel pratique sur la lutte antipaludique dans les situations durgence complexes (labor avec le concours de plusieurs partenaires institutionnels) ; et (viii) trois manuels de formation.

Financement de la lutte antipaludique

Il est prvu que les fonds aects la lutte antipaludique en provenance de lensemble des sources de nancements internationaux et nationaux atteignent US$ 2,5 milliards en 2012, cest--dire un

montant sensiblement infrieur aux ressources ncessaires pour atteindre les cibles xes au niveau mondial. 3. Les nancements internationaux allous aux pays dendmie palustre ont nettement augment, passant dun peu moins de US$ 100 millions en 2000 US$ 1,6 milliard en 2011 et ont t estims US$ 1,94 milliard en 2012 et 1,97 milliards en 2013. Toutefois, laugmentation des nancements internationaux a ralenti au cours des dernires annes, passant une moyenne de 4 % par an entre 2009 et 2013, par rapport une moyenne annuelle de 43 % entre 2005 et 2009. 4. Les donnes soumises suggrent que le nancement national de la lutte contre le paludisme a augment au cours de la priode 2005-2012, passant de US$ 436 millions en 2005 US$ 522 millions en 2012. Laugmentation des dpenses nationales consacres au paludisme a t estime un taux annuel de 4 % entre 2005 et 2012. 5. Dans le Plan daction mondial contre le paludisme (GMAP) du partenariat RBM en 2008, les besoins en ressources lchelle mondiale ont t estims plus de US$ 5,1 milliards par an entre 2011 et 2020. En combinant les fonds nationaux et internationaux, les ressources disponibles pour la lutte antipaludique dans le monde ont t estimes US$ 2,5 milliards en 2012, laissant un cart de US$ 2,6 milliards. Les prvisions pour les ressources nationales et internationales disponibles entre 2013 et 2016 indiquent que le nancement total de la lutte contre le paludisme atteindra environ US$ 2,85 milliards entre 2014 et 2016, un montant sensiblement infrieur aux besoins pour concrtiser laccs universel aux interventions antipaludiques. 6. Les nancements internationaux de la lutte antipaludique ont vis les pays o le revenu national brut par habitant tait le plus faible et o les taux de mortalit taient les plus levs, notamment les pays dAfrique. Toutefois, les nancements nationaux sont plus levs dans les pays les plus riches et plus faibles dans les pays o les taux de mortalit imputables au paludisme sont plus levs. Les faibles niveaux de dpenses intrieures des pays o le fardeau de la maladie est le plus lourd sexpliquent principalement par un revenu intrieur par habitant plus faible dans ces pays. 7. Il existe des disparits entre les degrs de priorit accords la lutte contre le paludisme par les gouvernements nationaux ayant des niveaux de ressources disponibles similaires. Les pays qui font preuve dun engagement plus important, mesur par un indice de priorit des investissements nationaux, ont eu davantage de succs dans la rduction de lincidence des cas de paludisme entre 2000 et 2012 que les autres pays.

tions de lOMS prconisant la fourniture de MII toutes les personnes exposes au paludisme. Au total, 88 pays, dont 39 en Afrique, distribuent gratuitement des MII. 9. Chaque anne, selon les estimations, au moins 150 millions de MII sont ncessaires pour maintenir un approvisionnement de 450 millions de MII dans les foyers pour une priode de trois ans et protger toutes les populations risque de paludisme en Afrique subsaharienne. Le nombre annuel de MII livres par les fabricants aux pays dendmie palustre en Afrique subsaharienne a augment pour passer de 6 millions en 2004 145 millions en 2010. Toutefois, en 2011, seulement 92 millions de MII ont t livrs par les fabricants et leur nombre tait de seulement 70 millions en 2012. Le nombre estim de MII livres en 2013 (136 millions) et le nombre de MII couvertes par des dons en 2014 (environ 200 millions) sont proches du nombre de MII ncessaire tous les ans pour protger toutes les populations risque. Pourtant, malgr laugmentation des livraisons annuelles, le nombre total de MII sur trois ans (400 millions), cumulant les MII livres en 2012, celles dont la livraison est estime pour la n de 2013 et celles pour lesquelles le nancement a t runi pour 2014, reste infrieur au nombre minimum requis pour protger toutes les personnes exposes au paludisme. Les niveaux adapts de livraison de MII requis doivent tre assurs chaque anne, pour garantir la disponibilit des MII dans les foyers et laccs une MII toute personne risque de paludisme. 10. Le pourcentage de mnages possdant au moins une MII en Afrique subsaharienne a augment selon les estimations, passant de 3 % en 2000 56 % en 2012, puis a lgrement diminu pour passer 54 % en 2013. Le pourcentage de la population ayant accs une MII au sein de son foyer a augment pendant la mme priode, pour atteindre 44 % en 2012 et 42 % en 2013. La proportion de la population dormant sous une MII, reprsentant la population directement protge, a t estime 38 % en 2012 et 36 % en 2013. 11. La comparaison du pourcentage de la population ayant un accs une MII et du pourcentage dormant sous cette moustiquaire laisse penser quune forte proportion (86 %) de la population ayant accs cette protection lutilise rellement, indiquant que les eorts visant encourager son utilisation ont t ecaces. Le principal obstacle empchant un plus grand nombre de personnes exposes au paludisme de dormir sous une MII se rsume la disponibilit insusante des moustiquaires. 12. Lutilisation de MII au sein des populations vulnrables, comme les femmes enceintes et les enfants de moins de cinq ans, est suprieure la frquence de son utilisation en population gnrale. Cela indique que ces groupes restent mieux protgs tandis que les pays intensient leurs eorts vers une couverture universelle des MII, et souligne le besoin daugmenter laccs cette moustiquaire pour toutes les personnes risque.

Progrs raliss dans la lutte antivectorielle

En Afrique subsaharienne, le pourcentage de la population ayant accs une MII au sein de leur foyer a fortement augment entre 2005 et 2011, mais a plafonn ces deux dernires annes pour repasser 42 % en 2013. Des distributions plus importantes de MII au cours des deux prochaines annes pourraient accrotre la couverture.

Pulvrisations intradomiciliaires dinsecticides eet rmanent (PII)

13. Les PII laide dinsecticides eet rmanent constituent encore un outil de lutte antivectorielle puissant destin rduire ou interrompre la transmission du paludisme. En 2012,
WORLD MALARIA REPORT 2013 | xvii

Moustiquaires imprgnes dinsecticide

8. Ds 2012, 34 pays de la Rgion Afrique et 82 pays situs dans dautres rgions du monde avaient adopt les recommanda-

88 pays, dont 40 pays dans la Rgion Afrique, recommandaient les PII dans la lutte contre le paludisme. 14. En 2012, 135 millions de personnes (4 % de la population mondiale expose) taient protgs par des PII dans le monde. Dans la Rgion Afrique, la proportion de la population expose qui a t protge a augment, passant de moins de 5 % en 2005 11 % en 2010, puis est tombe 8 % en 2012, avec 58 millions de bnciaires. La diminution du nombre de personnes protges par des PII en Afrique semble en partie due une augmentation du recours des insecticides non-pyrthrinodes plus coteux, en raction la menace de la rsistance aux insecticides dans un contexte de budgets allous aux PII limits. Lutilisation dinsecticides non pyrthrinodes pour les PII peut devenir de plus en plus importante en tant quoutil de gestion de la rsistance, car actuellement toutes les MII approuves sont base de pyrhrinode.

19. Dans 26 pays sur les 36 pays de la Rgion Afrique o la transmission du paludisme est de modre lev, qui ont adopt le TPIp en tant que politique nationale et pour lesquels des donnes sont disponibles, 64 % (mdiane) des femmes enceintes se prsentant dans des tablissements de soins prnatals ont reu en 2012 au moins une dose du traitement prventif intermittent durant leur grossesse, 38 % ont reu au moins deux doses et 23 % au moins trois doses. Dans les 13 pays de la Rgion Afrique disposant de donnes provenant denqutes auprs des mnages sur la priode 2010-2012, la moyenne pondre de toutes les femmes ayant reu une dose de TPIp pendant leur grossesse tait de 37 % ; 23 % avaient reu deux doses et 8 % trois doses. 20. Depuis octobre 2012, lOMS recommande dadministrer une dose de TPIp chaque visite prnatale programme aprs le premier trimestre de grossesse. Lanalyse des donnes issues denqutes auprs des mnages indique que la proportion de femmes enceintes qui reoit le TPIp est trs infrieure celle des femmes se prsentant dans des tablissements prnatals. Le pourcentage estim de visites dans ces tablissements au cours desquelles le TPIp pourrait tre administr mais nest pas administr est lev, se montant 72 %. La proportion de femmes bnciant du TPIp au cours de leurs visites prnatales est infrieure au pourcentage de femmes recevant lanatoxine ttanique (une autre composante cl des soins prnatals). Cet cart indique que la capacit fournir des services prventifs pendant les visites prnatales est trs leve, et que les obstacles au TPIp peuvent tre franchis. 21. Tous les nourrissons exposs un risque dinfection par P. falciparum dans des pays dAfrique subsaharienne o lintensit de la transmission est comprise entre modre et leve et o les niveaux de rsistance des parasites aux agents recommands (la sulfadoxine-pyrimthamine) sont faibles, devraient recevoir un traitement prventif contre le paludisme par les services de vaccination, selon des intervalles dnis correspondant aux calendriers de vaccination systmatique. Seul un pays, le Burkina Faso, a fait du TPI un lment de sa politique nationale dans le cas des nourrissons depuis sa recommandation par lOMS en 2009. 22. En mars 2012, lOMS a publi des recommandations sur la chimioprvention saisonnire du paludisme (CSP) chez les enfants gs de 3 59 mois, et en aot 2013, lOMS a publi un manuel pratique pour une mise en uvre de la CSP. Deux pays dendmie ont adopt la CSP et plusieurs pays impliqus dans lvaluation de la politique ont indiqu quils prvoyaient dadopter cette politique et dlargir la couverture de la CSP dautres populations que celle de ltude.

Rsistance aux insecticides

15. Une rsistance des moustiques au moins un insecticide utilis dans la lutte contre le paludisme a t constate dans au moins 64 pays dendmie palustre dans le monde. En mai 2012, lOMS et le partenariat RBM ont publi le Plan mondial pour la gestion de la rsistance aux insecticides chez les vecteurs du paludisme (GPIRM). Le GPIRM est une stratgie cinq piliers de gestion de la menace de rsistance aux insecticides. Les parties prenantes de la communaut mondiale de lutte contre le paludisme ont entam des interventions lies la mise en uvre de la stratgie labore dans le Plan mondial pour la gestion de la rsistance aux insecticides. 16. Le suivi de la rsistance aux insecticides est une composante indispensable au dploiement des interventions de lutte antivectorielle fondes sur des insecticides. En 2012, 58 pays ont signal avoir adopt une politique de suivi systmatique de la rsistance aux insecticides.

Progrs raliss en matire de chimioprvention

Parmi les pays africains soumettant ces donnes lOMS en 2012, le pourcentage mdian de femmes enceintes se prsentant dans des tablissements de soins prnatals et ayant reu au moins une dose du traitement prventif intermittent (TPI) durant leur grossesse tait de 64 % tandis que 38 % avaient reu au moins deux doses et 23 % au moins trois doses, pointant vers une marge damlioration considrable dans le domaine de la protection des femmes enceintes. 17. En Afrique subsaharienne, il a t estim que 35 millions de femmes enceintes et une grande partie des 26 millions de nourrissons ns chaque anne tireraient avantage dune TPI. En outre, environ 25 millions denfants dans la rgion sahlienne de lAfrique subsaharienne pourraient tre protgs contre le paludisme au moyen dune chimioprvention saisonnire du paludisme (CSP). 18. Au total, en Afrique subsaharienne, 36 pays o lintensit de la transmission du paludisme est comprise entre modre et leve ont adopt ds la n 2012 le TPI pour femmes enceintes (TPIp) comme politique nationale. Dans la Rgion Pacique occidental, la Papouasie-Nouvelle-Guine a galement adopt cette politique en 2009.
xviii | WORLD MALARIA REPORT 2013

Progrs raliss en matire de test de diagnostic et de traitement antipaludique

Les achats de tests de diagnostic rapide (TDR) et de combinaisons thrapeutiques base dartmisinine (CTA) sont en augmentation tout comme le taux noti des tests de diagnostic dans le secteur public de la Rgion Afrique qui est pass de 37 % en 2010 61 % en 2012. En consquence, une rduction du nombre de cas suspects de paludisme traits prsomptivement par des antipaludiques a t observe. Toutefois, des millions de personnes chez qui un paludisme

est suspect ne reoivent toujours pas de test de diagnostic, et de nombreuses personnes dont linfection est conrme ne bncient pas dun traitement antipaludique appropri satisfaisant aux normes dassurance qualit.

vivax doit tre complt par ladministration de primaquine pendant 14 jours an dviter les rechutes. 29. Selon les rapports de fabricants et le Dispositif pour des mdicaments abordables pour le paludisme (DMAp), le nombre de traitements par CTA livrs aux secteurs publics et privs dans le monde a augment, passant de 11 millions en 2005 76 millions en 2006, pour atteindre 331 millions en 2012. Cette hausse des achats de CTA en 2012 sexplique en grande partie par une augmentation denviron 50 % des livraisons dans le secteur public entre 2011 et 2012. Lachat de mdicaments pour le secteur public et le secteur priv par le DMAp qui est actuellement dans une phase de transition vers une ventuelle intgration dans un processus doctroi de subventions systmatique pour le Fonds mondial de lutte contre le sida, la tuberculose et le paludisme (le Fonds mondial), sest lgrement ralenti, passant de 156 millions de traitements en 2011 150 millions en 2012. 30. Il est dicile de savoir dans quelle mesure les patients dont le paludisme a t conrm ont reu des traitements antipaludiques car les informations reliant le test de diagnostic au traitement ont t limites dans les deux enqutes auprs des mnages et les systmes dinformation sanitaire courants. Il est possible destimer la proportion de patients dans le secteur public potentiellement traite par CTA (plutt que par un antipaludique moins ecace) en comparant le nombre de traitements par CTA distribus par les programmes nationaux au nombre de cas de paludisme prsums (traits sans test pralable) et de cas de paludisme P. falciparum conrms (par examen microscopique ou TDR) (corrigs pour lexhaustivit des donnes soumises, ou estims dans les situations o les donnes nont pas t soumises). Cette proportion varie en fonction des Rgions de lOMS, mais a augment au l du temps dans la Rgion Afrique, o elle a atteint 60 % en 2012. 31. Dans neuf pays de la Rgion Afrique o plus dune enqute auprs des mnages a t mene entre 2006 et 2012, la proportion denfants fbriles sous antipaludiques ayant reu une CTA a augment au l du temps, dans le secteur public comme le secteur priv. Dans les enqutes les plus rcentes, le pourcentage mdian denfants sous antipaludiques ayant reu une CTA tait de 68 % ; toutefois, une part importante denfants ntant pas prsente aux services de soins pour un motif de vre, et tous les enfants chez qui un paludisme est suspect ne recevant pas un test diagnostique, le pourcentage de tous les enfants atteints de paludisme recevant une CTA est probablement trs infrieur. Dans 26 enqutes auprs des mnages menes entre 2010 et 2012 se fondant sur un rsultat positif au TDR chez les enfants fbriles comme indicateur indirect pour conrmer le diagnostic de paludisme, le pourcentage moyen de tous les enfants dont linfection a t conrme et qui ont reu une CTA tait de 16 % (extrmes : 1 %-42 %). Un accs accru aux soins en cas de vre, ainsi que des tests de diagnostic et une prise en charge thrapeutique adapte dans tous les lieux de soins, sont indispensables pour garantir que tous les patients sourant de paludisme reoivent un traitement rapide et ecace. 32. Dans la Rgion Afrique en 2012, le nombre total de tests (examens microscopiques et TDR) tait presque quivalent au nombre de CTA distribues par les programmes nationaux de lutte contre le paludisme, ce qui signie que le rapport a augment compar aux annes prcdentes. Toutefois,
WORLD MALARIA REPORT 2013 | xix

Tests de diagnostic
23. La mise en uvre universelle des tests de diagnostic dans les secteurs publics et privs rduirait considrablement les besoins en traitements antipaludiques dans le monde. En 2012, 41 des 44 pays de la Rgion Afrique achant encore des taux de transmission du paludisme et 48 sur 55 pays des autres Rgions de lOMS ont signal avoir adopt une politique visant fournir le diagnostic parasitologique toutes les tranches dge, ce qui reprsente six pays de plus quen 2009 pour la Rgion Afrique. 24. Le test de diagnostic du paludisme est oert gratuitement dans le secteur public de 84 pays dans le monde. La proportion des cas suspects de paludisme soumis un test de diagnostic dans le secteur public a augment, passant de 37 % en 2010 61 % en 2012 dans la Rgion Afrique et de 44 % 64 % dans le monde. Lessentiel de cette augmentation dans la Rgion Afrique est imputable une utilisation accrue des TDR, qui reprsente 40 % de tous les cas dpists dans la Rgion en 2012. 25. Le nombre de patients soumis un examen microscopique a augment, pour culminer 188 millions en 2012, tandis que lInde reprsente plus de 120 millions dexamens de prlvements sanguins sur lames. Le nombre de TDR fournis par les fabricants est pass de 88 millions en 2010 205 millions en 2012. Ce chire comprend les ventes accrues pour les tests spciques de P. falciparum et les tests combins qui peuvent dtecter plus dune espce de parasites. 26. Au total, 48 pays ont dclar avoir dploy des TDR au niveau communautaire et 15 millions de patients ont t soumis un test de diagnostic grce ces programmes en 2012, selon les notications. Daprs lanalyse des donnes issues des enqutes auprs des mnages de 14 pays menes entre 2010 et 2012, il semblerait que les tests de diagnostic soient moins rpandus dans le secteur priv que dans le secteur public. 27. Les TDR sont de plus en plus utiliss pour le dpistage des cas suspects de paludisme dans les tablissements de sant, notamment pour le diagnostic de P. vivax. Sur les 42 pays prcisant le type de TDR utilis, 15 ont dclar avoir dploy des TDR capables de dpister spciquement P. vivax. Dans ces pays, le pourcentage de cas infects par P. vivax conrms par TDR (plutt que par microscopie) tait similaire au pourcentage de cas infects par P. falciparum conrms par TDR.

Traitement
28. Une CTA est recommande dans le traitement de premire intention du paludisme P. falciparum, le parasite Plasmodium le plus dangereux qui infecte les humains. En 2012, 79 pays et territoires ont adopt la CTA en traitement de premire intention pour le paludisme P. falciparum. Le paludisme P. vivax doit tre trait par la chloroquine partout o cet antipaludique reste ecace ou par une CTA dans les zones o P. vivax est rsistant la chloroquine. Le traitement du paludisme P.

dans la plupart des zones dendmie palustre, le rapport attendu devrait dpasser deux, car moins de la moiti des cas suspects de paludisme seront conrms et ncessiteront un traitement par une CTA.

faibles et les dicults pour les renforcer sont plus importantes l o le fardeau du paludisme est le plus lourd. 36. En 2012, les systmes dinformation sanitaires courants nont dpist que 14 % des cas estims dans le monde. Les taux de dpistage des cas sont les plus faibles dans les pays o le nombre de cas de paludisme est le plus lev. De mme, le pourcentage de dcs notis est aussi le plus faible dans les pays o le nombre de dcs dus au paludisme est le plus lev. Les systmes de surveillance ne doivent pas dpister tous les cas pour valuer les tendances de manire able ; toutefois, les actions de dpistage doivent tre raisonnablement uniformes dans le temps. Les pays o le nombre de cas estims est moindre semblent plus mme destimer les tendances dans lincidence du paludisme. Dans les 41 pays reprsentant 80 % des cas estims en 2000, il nest pas possible dvaluer de manire able les tendances 2000-2012 du paludisme laide des donnes soumises lOrganisation. Ainsi, les systmes dinformation sont les plus faibles l o le fardeau du paludisme est le plus lourd. 37. Les enqutes auprs des mnages sont plus frquentes dans les pays o le nombre de cas de paludisme est le plus lev tandis que la transmission de donnes systmatique est moins frquente. Cinquante pays, parmi lesquels 34 situs dans la Rgion Afrique, ont men au moins une enqute auprs des mnages au cours de la priode de trois ans de 2011 2013. Les indicateurs les plus frquemment mesurs taient ceux de la disponibilit des MII et de lutilisation dantipaludiques. Seules 25 % des enqutes posaient des questions sur les cas de vre bnciant dune piqre au bout du doigt ou au talon, alors que 90 % interrogeaient sur les traitements antipaludiques. Cette caractristique devra changer si les progrs vers le dpistage universel doivent tre suivis. Le nombre denqutes mesurant la prvalence parasitaire a augment depuis 2005, passant 81 % de toutes les enqutes menes en 2011 et 2013.

Rsistance aux mdicaments antipaludiques

33. LOMS recommande de retirer progressivement du march les monothrapies base dartmisinine par voie orale et de les remplacer par des CTA, une politique adopte par lAssemble mondiale de la sant en 2007. Le nombre de pays autorisant encore la commercialisation de ces produits a diminu, passant de 55 pays en 2008 9 pays en novembre 2013, dont 6 se trouvent dans la Rgion Afrique. Le nombre de compagnies pharmaceutiques commercialisant ces produits a chut, passant de 38 en 2010 30 en 2013. La plupart des pays qui autorisent encore la commercialisation des monothrapies se trouvent dans la Rgion Afrique, alors que la majorit des fabricants sont implants en Inde. 34. 34. Les tudes relatives lecacit thrapeutique restent la norme de rfrence pour orienter les politiques sur les mdicaments. Elles doivent tre ralises tous les deux ans. En 2011 et 2012, des tudes decacit au sujet des traitements antipaludiques de premire ou de seconde intention ont t eectues dans 48 des 67 pays (72 %) o tudier lecacit de ce type de mdicaments face P. falciparum est possible, ce qui reprsente une hausse par rapport aux 31 pays sur 75 (41 %) en 2008-2009. (Ces tudes sont impossibles dans 32 pays dendmie, du fait de la faible incidence du paludisme ou du fait dune endmie uniquement lie P. vivax.) 35. 35. Des cas possibles de rsistance des parasites aux artmisinines ont t identis dans quatre pays de la sous-rgion du Grand Mkong : le Cambodge, le Myanmar, la Thalande et le Viet Nam. Malgr les changements observs dans la sensibilit des plasmodies aux artmisinines, les CTA continuent gurir des patients lorsque le mdicament partenaire reste ecace. Toutefois, dans la province de Pailin au Cambodge, on a observ une rsistance aux deux composants des CTA multiples. Des dispositions spciales ont donc t prises pour une thrapie sous surveillance directe par une association ne contenant pas dartmisinine (atovaquone-proguanil). En avril 2013, lOMS a publi Emergency response to artemisinin resistance in the Greater Mekong subregion : Regional framework for action 2013 2015 (Riposte durgence la rsistance lartmisinine dans la sous-rgion du Grand Mkong : un cadre dintervention rgional pour 2013-2015). Le document dcrit les domaines prioritaires o des actions sont requises dans les annes venir pour juguler la rsistance lartmisinine.

Impact de la lutte antipaludique

Depuis 2000, plus de la moiti des pays dendmie palustre cette anne-l ont enregistr des diminutions de lincidence de cas de paludisme conrms ou de la notication des admissions et des dcs (ou les deux). Dans le monde, entre 2000 et 2012, les taux de mortalit estims dus au paludisme ont chut de 45 % dans toutes les tranches dge et de 51 % chez les enfants de moins de cinq ans. Si le taux annuel de diminution observ au cours des 12 dernires annes se conrme, alors il est prvu que les taux de mortalit dus au paludisme diminuent de 56 % dans toutes les tranches dge et de 63 % chez les enfants de moins de cinq ans dici 2015. 38. En 2012, 3,4 milliards de personnes taient exposes au paludisme selon les estimations. Sur ce total, 2,2 milliards couraient un faible risque (< un cas noti pour 1 000 habitants), parmi lesquels 94 % ne vivaient pas dans la Rgion Afrique. Le 1,2 milliard de personnes haut risque (> un cas pour 1 000 habitants) vivait principalement dans la Rgion Afrique (47 %) et la Rgion dAsie du Sud-Est (37 %). 39. Si lon se fonde sur les donnes soumises, 59 pays sur 103 o la transmission du paludisme tait active en 2000 atteignent lOMD dinverser la tendance du paludisme. Parmi ceux-ci, 52 sont en bonne voie pour atteindre les cibles xes par lAssemble mondiale de la sant et par le partenariat RBM : rduire de

Surveillance, suivi et valuation du paludisme

Les rapports soumis en 2012 par 62 pays sur 103 o la transmission du paludisme persistait en 2000, ont t considrs comme susamment cohrents pour tirer des conclusions ables sur les tendances en matire de paludisme entre 2000 et 2012. Dans les 41 autres pays reprsentant 80 % des cas estims, il na pas t possible dvaluer de manire able les tendances du paludisme laide des donnes soumises lOrganisation. Les systmes dinformation sont plus
xx | WORLD MALARIA REPORT 2013

75 % le nombre de cas de paludisme dici 2015, et notamment dans huit pays de la rgion Afrique. 40. La diminution de lincidence de P. falciparum est, en moyenne, plus importante que celle de P. vivax, laissant penser que P. vivax ragit plus lentement aux interventions de lutte, probablement en raison de ses caractristiques biologiques. En consquence, de nombreux NMPC doivent mettre laccent sur la lutte contre P. vivax tandis que llimination est proche, notamment dans les zones hors dAfrique subsaharienne. Dans les pays o les deux espces sont transmises, P. vivax prdomine dans les pays en phase de pr-limination et dlimination. 41. Sur les 97 pays o la transmission perdure en 2013, 12 sont classs dans la phase de pr-limination dans la lutte antipaludique, et 7 dans la phase dlimination. Sept autres pays sont en phase de prvention de la rintroduction de la maladie. En 2012, la Rgion Europe a noti seulement 255 cas autochtones ; en consquence, elle est sur le point de raliser lobjectif dlimination du paludisme de la Rgion dici 2015, conformment lobjectif x dans la Dclaration de Tashkent (2005). Toutefois, des ambes rcentes en Grce et en Turquie soulignent la menace continue de rintroduction et la ncessit dassurer une vigilance permanente an de garantir que toute rsurgence est rapidement jugule. 42. Les 52 pays o une diminution de lincidence du paludisme de 75 % est prvue dici 2015 (selon les donnes soumises) reprsentaient seulement 8 millions de cas (4 %) sur un nombre total estim de 226 millions de cas en 2000. Cette situation sexplique en partie par les progrs plus rapides dans les pays o le nombre de cas est plus faible, mais la qualit insusante des donnes de surveillance soumises par les pays o le nombre de cas est plus lev joue aussi un rle. Une amlioration de la surveillance et de lvaluation dans les pays les plus accabls par le fardeau du paludisme est essentielle pour valuer correctement limpact des investissements pour la lutte antipaludique. 43. Les pays ayant le nombre de cas le plus lev tant moins susceptibles de soumettre des donnes susamment cohrentes, il est essentiel dextrapoler les tendances dans ces pays partir des estimations du nombre de cas, plutt que des donnes de surveillance. Le nombre de cas de paludisme a t estim 207 millions dans le monde en 2012 (marge dincertitude : 135-287 millions). La majorit des cas (80 %) sont situs en Afrique subsaharienne selon les estimations. Environ 9 % des cas estims dans le monde sont dus P. vivax, mme si la proportion hors du continent africain est de 50 %. Lincidence du paludisme a chut de 29 % dans le monde entre 2000 et 2012 et de 31 % dans la Rgion Afrique, selon les estimations. Si le taux annuel de diminution observ au cours des 12 dernires annes perdure, alors lincidence des cas de paludisme diminuera de 36 % dans le monde dici 2015 et de 40 % dans la Rgion Afrique selon les prvisions. 44. Il a t estim que 627 000 dcs taient imputables au paludisme dans le monde en 2012 (marge dincertitude : 473 000-789 000). La plupart des dcs estims (90 %) ont lieu en Afrique subsaharienne et chez les enfants de moins de cinq ans (77 %). Entre 2000 et 2012, les taux de mortalit estims imputables au paludisme ont diminu de 45 % dans le monde et de 49 % dans la Rgion Afrique ; chez les enfants de moins de cinq ans, les dcs ont diminu de 51 % dans le monde

et de 54 % dans la Rgion Afrique, selon les estimations. Si le taux annuel de diminution observ au cours des 12 dernires annes se conrme, alors les taux de mortalit imputables au paludisme diminueront de 56 % dans le monde dici 2015 et de 62 % dans la Rgion Afrique, selon les prvisions. Le pourcentage de dcs prvu chez les enfants de moins de cinq ans devrait diminuer de 63 % dans le monde et de 68 % dans la Rgion Afrique dici 2015. 45. Le rythme de la diminution des taux de mortalit estims imputables au paludisme sest acclr partir de 2005, mais a ralenti entre 2011 et 2012. Ce ralentissement sexplique en partie parce que la modlisation qui est applique pour estimer les taux de dcs chez les enfants de moins de cinq ans en Afrique utilise les donnes de la couverture des MII pour ajuster le pourcentage de tous les dcs dus au paludisme, alors que cette couverture a stagn entre 2011 et 2012 suite des baisses du nancement de la lutte contre le paludisme en 2011. 46. Plus de 80 % des dcs imputables au paludisme en 2012 ont eu lieu dans seulement 17 pays, et 80 % des cas de paludisme sont comptabiliss dans 18 pays, notamment la Rpublique dmocratique du Congo et le Nigeria, reprsentant eux deux 40 % du total mondial, selon les estimations. Les cibles de rduction des cas et des dcs ne seront pas atteintes, moins que des progrs importants soient raliss dans les pays reprsentant la part du fardeau du paludisme la plus lourde. 47. Quatre pays reprsentent plus de 80 % des cas dus P. vivax (thiopie, Inde, Indonsie et Pakistan) selon les estimations. Le paludisme P. vivax a t associ un paludisme svre et au dcs, mme si le risque dinfection svre et les taux de ltalit dus une infection P. vivax nont pas t fermement tablis. Les comorbidits, notamment un tat de malnutrition concomitant, sont suspectes daccrotre le risque dinfection svre P. vivax, mme si le risque reste mal dni. Des tudes plus approfondies sont ncessaires pour aner les connaissances existantes sur la forme de paludisme P. vivax svre et les risques de maladie svre et de dcs imputables cette infection. 48. Les progrs visant rduire lincidence des cas de paludisme et les taux de mortalit ont t plus rapides dans les pays o le nombre de cas et de dcs tait plus faible en 2000. Toutefois, la vaste majorit du nombre de cas et de dcs vits entre 2000 et 2012 a t observe dans des pays o le fardeau du paludisme tait le plus lourd en 2000. Si lincidence du paludisme et les taux de mortalit en 2000 taient rests stables au cours de la dcennie, 500 millions de cas supplmentaires et 3,3 millions de dcs en plus auraient t dplorer entre 2001 et 2012. La majorit des cas de paludisme vits (67 %) et des vies sauves (93 %) est situe dans la Rgion Afrique. 49. Il a t estim que sur les 3,3 millions de dcs vits entre 2001 et 2012, 3 millions (90 %) concernaient des enfants de moins de cinq ans en Afrique subsaharienne. Ils reprsentent environ 20 % des 15 millions de dcs qui ont t vits depuis 2000 parmi les moins de cinq ans en Afrique subsaharienne. Par consquent, les diminutions du nombre de dcs dus au paludisme ont considrablement contribu progresser vers la ralisation de lOMD 4, qui est de rduire de deux tiers, entre 1990 et 2015, le taux de mortalit des enfants de moins de cinq ans.

WORLD MALARIA REPORT 2013 | xxi

Prefacio
Dra. Margaret Chan Directora General Organizacin Mundial de la Salud (OMS)
Este ao, el Informe Mundial sobre el Paludismo documenta un progreso notable en la lucha mundial contra la malaria, e incluye una actualizacin de la carga por malaria para el periodo 2000 a 2012. El reporte muestra que el aumento del compromiso poltico y la ampliacin de las inversiones en malaria a nivel mundial desde el 2000 han dado lugar a grandes avances contra esta enfermedad prevenible, salvando un estimado de 3.3 millones de vidas. Cada ao entendemos mejor las tendencias de la malaria a nivel mundial y la carga de la enfermedad, medidos en relacin a la situacin en el 2000. De acuerdo a los ltimos estimados las tasas de mortalidad por malaria se redujeron aproximadamente en 45% a nivel mundial y en 49% en la regin africana entre 2000 y 2012. Durante el mismo periodo, las tasas de incidencia de malaria disminuyeron en 29% alrededor del mundo, y en 31% en la regin de frica. Estas reducciones tan sustanciales ocurrieron como resultado de un incremento en las intervenciones para el control del vector, realizacin de pruebas de diagnstico y tratamiento con terapias combinadas con artemisinina o TCA. Sin embargo, este progreso no es motivo de satisfaccin. Los nmeros absolutos de casos y muertes por malaria no estn disminuyendo tan rpido como deberan. La enfermedad todava cobr un estimado de 627 000 vidas en 2012, principalmente de nios de menos de cinco aos de edad en frica. Esto signica que se pierden 1300 vidas jvenes por malaria cada da un fuerte recordatorio que todava queda un largo camino por recorrer para el triunfo sobre este enemigo tan antiguo. El hecho que tanta gente se est muriendo por las picaduras de mosquitos es una de las mayores tragedias del siglo 21. Si el compromiso poltico se desvanece, el gran progreso que se ha logrado podra perderse, en algunos lugares en una sola temporada de transmisin. En los ltimos cuantos aos, hemos comenzado a ver los primeros signos de una posible desaceleracin. En 2011 y 2012, la distribucin de mosquiteros insecticidas de larga duracin en pases endmicos se desaceler y los programas de rociado residual intradomiciliario se estabilizaron. Durante este periodo, las tasas de mortalidad por malaria continuaron disminuyendo, pero a un ritmo ms lento. En 2013, las distribuciones de mosquiteros volvieron a incrementarse, y los planes en curso para el prximo ao son todava ms fuertes. No obstante, todava se necesitarn mayores esfuerzos para proteger a todos los que estn en riesgo. A medida que la comunidad internacional se mueve gradualmente hacia una agenda de desarrollo post-2015, no debemos perder de vista lo que esperan de nosotros las poblaciones ms vulnerables del mundo. El concepto de cobertura universal en salud representa tanto un valor social como un acercamiento a la atencin en salud que genera una mejor salud para poblaciones completas, reduce las inequidades sociales, y protege a las personas de pobreza inducida por los costos de la atencin en
xxii | WORLD MALARIA REPORT 2013

salud. Es un concepto clave que ya est en el centro del debate de la salud mundial, y tambin en el debate acerca de la prxima serie de objetivos del desarrollo. El progreso contra la malaria proporciona una buena evidencia de los benecios tangibles de que la poblacin tenga acceso a intervenciones que salvan vidas. El mundo tambin necesita mantenerse enfocado en atender el dcit mundial de nanciamiento para la prevencin y control de la malaria. El nanciamiento disponible en la actualidad est muy por debajo de lo requerido para alcanzar el acceso universal a las intervenciones en malaria. Para alcanzar nuestro objetivo, necesitamos redoblar esfuerzos en la expansin de las herramientas para el control vectorial. Tambin necesitamos asegurar que los grupos ms vulnerables nios menores de cinco aos y mujeres embarazadas tengan acceso a las terapias preventivas intermitentes recomendadas por la OMS, cuando sea apropiado. Si bien en aos recientes el avance en cuanto al aumento en la realizacin de pruebas de diagnstico y el tratamiento de calidad asegurada ha sido inmenso, estamos muy lejos de alcanzar el acceso universal. Adems, la resistencia del parsito a la artemisinina el componente central del medicamento antimalrico ms efectivo en el mundo y la resistencia del mosquito a los insecticidas siguen siendo motivo de gran preocupacin. Si no se tratan con la urgencia del caso, podran poner en riesgo el progreso tan grande que se ha realizado desde el 2000. Aunque la OMS ha emitido estrategias mundiales para hacer frente a estos desafos, el avance en cuanto a su adopcin por parte de los pases ha sido lento, principalmente por falta de nanciamiento. En abril de 2013, en el Da Mundial de la Malaria, la OMS lanz una Respuesta de emergencia a la resistencia a la artemisinina en la subregin del Gran Mekong para guiar a los pases en la ampliacin e implementacin de esfuerzos para eliminar los parsitos resistentes. El dcit de nanciamiento para este esfuerzo tambin es considerable. El fortalecimiento de las infraestructuras de salud, registro de datos vitales y los sistemas de vigilancia tambin es crtico para un seguir avanzando. En base a los datos reportados, 59 pases estn en camino de alcanzar el objetivo de reducir la incidencia de malaria, y 52 pases estn en camino de reducir sus tasas de incidencia de casos de malaria en un 75%, en lnea con los objetivos para el 2015 de la Asamblea Mdica Mundial y de la Alianza para Hacer Retroceder la Malaria. Sin embargo, estos 52 pases aportaron solo un 4%, u ocho millones, del total de casos estimados de malaria alrededor del mundo. En 41 pases endmicos, incluyendo pases con las cargas ms altas por malaria, no se puede hacer una evaluacin conable respecto a las tendencias de la enfermedad. Se necesita un esfuerzo conjunto para mejorar los sistemas de vigilancia y eliminar esta brecha en el conocimiento sobre la situacin de la malaria. La OMS est muy agradecida por el compromiso de los ministerios de salud de pases endmicos y sus mltiples socios para el desarrollo. Estamos conados que si continuamos determinados y actuamos con prontitud, podremos derrotar a este antiguo enemigo de una vez por todas.

Resumen y Puntos Clave

El Informe Mundial sobre el Paludismo 2013 resume la informacin recibida de pases endmicos para malaria y otras fuentes, y actualiza los anlisis presentados en el informe del 2012. Resalta el progreso que se ha alcanzado hacia los objetivos mundiales para el control de la malaria establecidos para 2015, y describe los retos actuales para el control y eliminacin de la malaria a nivel mundial. Desde el ao 2000, la gran expansin en el nanciamiento y cobertura de los programas de control de la malaria ha llevado a una reduccin a gran escala de la incidencia y mortalidad por malaria. En base a los datos reportados, 59 de los 103 pases que haban tenido una transmisin activa de malaria en el ao 2000 estn alcanzando la meta de los Objetivos de Desarrollo del Milenio (ODM) de revertir la incidencia de la malaria. De estos, 52 pases estn en vas de alcanzar las metas de la Alianza para Hacer Retroceder la Malaria (RBM, por sus siglas en ingls) y de la Asamblea Mundial de la Salud (AMS) de reducir las tasas de incidencia de casos de malaria en un 75% para 2015, incluyendo 8 pases de la regin africana de la OMS. En 41 pases no es posible evaluar las tendencias utilizando los datos reportados, debido a inconsistencias en cuanto a la integridad de los reportes a lo largo del tiempo, a cambios en las prcticas de diagnstico o en el uso de los servicios de salud. Para estos pases, que aportaron el 80% de los casos en el ao 2000, las tendencias sobre malaria se deben inferir en base a estimados de las tasas de incidencia y mortalidad. Entre 2000 y 2012, las tasas estimadas de mortalidad por malaria a nivel mundial disminuyeron en un 45% en todos los grupos de edad, y en un 51% en nios menores de 5 aos. Si se mantiene la tasa anual de disminucin de los ltimos 12 aos, se anticipa que para 2015 las tasas de mortalidad por malaria disminuyan en 56% para todas las edades y en 63% en nios menores de 5 aos; esto representa un progreso sustancial hacia la meta de la AMS de reducir las tasas de mortalidad por malaria en un 75% para 2015. Los modelos de datos sugieren que se evitaron aproximadamente 3.3 millones de muertes por malaria entre 2001 y 2012, y que el 69% de vidas se salvaron en 10 de los pases con las mayores cargas por malaria en el 2000; por lo tanto, el progreso se est realizando donde ms interesa. Se estima que en Africa subsahariana se evitaron alrededor de 3 millones (90%) de muertes en nios menores de 5 aos de edad entre 2001 y 2012. Esto representa el 20% de las 15 millones de muertes en nios que se estima que han sido evitadas en Africa subsahariana desde el 2000, a travs de la reduccin general de las tasas de mortalidad infantil. Por lo tanto, la disminucin en las muertes por malaria han contribuido sustancialmente al progreso hacia alcanzar la meta del ODM 4, que es reducir en dos terceras partes la tasa de mortalidad de menores de 5 aos entre 1990 y 2015. Sin embargo, entre 2011 y 2012 disminuy el ritmo de reduccin de las tasas estimadas de mortalidad por malaria. Esta disminucin se debe en parte a que el modelo que se utiliza para estimar las muertes por malaria en nios menores de 5 aos de edad en frica utiliza la cobertura de mosquiteros tratados con insecticida (MTI) como un dato, y la cobertura de MTI se estanc en 2011-2012, luego de una disminucin en el nanciamiento para el control de la malaria en el 2011. En 2012, se estim que el nanciamiento de los programas de malaria fue de menos de la mitad de los 5.1 mil millones que se requieren a nivel mundial. As, millones de personas en riesgo de contraer malaria todava no tienen acceso a intervenciones como los MTI, rociado residual intradomiciliario (RRI), pruebas de diagnstico y terapias combinadas con artemisinina (TCA). Como resultado, se estima que en 2012 ocurrieron 207 millones de casos (intervalo de incertidumbre, 135-287 millones) y 627 000 muertes por malaria (intervalo de incertidumbre, 473 000789 000). Existe una necesidad urgente de aumentar el nanciamiento para el control de la malaria y ampliar la cobertura del programa de forma que puedan alcanzarse las metas internacionales para la reduccin de los casos y muertes por malaria.

Desarrollo de polticas
En 2013, despus de las reuniones del Comit Asesor en Polticas de Malaria (CAPM) de la OMS, se publicaron varias actualizaciones o nuevas polticas, manuales operacionales, planes e iniciativas para el control de la malaria.
1. El CAPM, que inici su funcionamiento en 2012, continu con su trabajo en 2013; su mandato es proporcionar asesoramiento estratgico y aportes tcnicos a la OMS en todos los aspectos del control y eliminacin de la malaria. De acuerdo con las recomendaciones del CAPM, la OMS public guas sobre un rango de polticas, incluyendo el logro de una cobertura universal con mosquiteros insecticidas de larga duracin (MILD), la estimacin de la longevidad de los mosquiteros, y el desarrollo de capacidades en entomologa de la malaria y control de vectores. 2. Otras guas publicadas por la OMS en 2013 incluyen (i) un manual operacional para el RRI; (ii) un manual operacional para el manejo de criaderos; (iii) procedimientos para el monitoreo de la resistencia a insecticidas en los mosquitos vectores de la malaria; (iv) una gua de campo sobre la quimioprevencin de la malaria estacional (SMC, por sus siglas en ingls); (v) un manual para el manejo de la malaria severa; (vi) un marco de accin para responder a la resistencia a artemisinina en la subregin del Gran Mekong; (vii) un manual de campo sobre el control de la malaria en emergencias complejas (desarrollado en conjunto con varias organismos asociados); y (viii) tres manuales de capacitacin.

Financiando el control de la malaria

Se estima que el total del nanciamiento nacional e internacional comprometido para el control de la malaria fue de US$ 2.5 mil millones en 2012 sustancialmente menor al monto que se necesitara para alcanzar las metas mundiales. 3. Los desembolsos internacionales para los pases endmicos para malaria han aumentado de forma marcada, de menos de US$ 100 millones en 2000 a US$1.6 mil millones en 2011, aproximadamente US$1.94 mil millones en 2012 y 1.97 mil millones en
WORLD MALARIA REPORT 2013 | xxiii

2013. Sin embargo, los aumentos en el nanciamiento internacional han disminuido en aos recientes a un promedio de 4% por ao entre 2009 y 2013, en comparacin con el promedio de 43% por ao entre 2005 y 2009. 4. Los datos reportados sugieren que a nivel mundial, el nanciamiento nacional para malaria aument durante el periodo 2005-2012 de US$ 436 millones en 2005 a US$ 522 millones en 2012. Se estima que el gasto pblico interno para malaria se elev a una tasa de 4% por ao entre 2005 y 2012. 5. En el Plan de Accin Mundial contra la Malaria (GMAP, por sus siglas en ingls) de 2008, de la iniciativa RBM, se estim que los recursos mundiales para el control de la malaria superaran los US$ 5.1 mil millones por ao entre 2011 y 2020. En 2012 se estim que combinando los fondos nacionales e internacionales disponibles a nivel mundial para el control de la malaria, los recursos fueron de US$ 2.5 mil millones, dejando una diferencia de US$ 2.6 mil millones. Las proyecciones de recursos nacionales e internacionales disponibles entre 2013 y 2016 indican que el total de nanciamiento para el control de la malaria alcanzar aproximadamente US$ 2.85 mil millones entre 2014 y 2016, lo que es considerablemente menor a la cantidad requerida para alcanzar el acceso universal a las intervenciones en malaria. 6. Las inversiones internacionales para el control de la malaria se han dirigido a pases con las tasas ms altas de mortalidad y presupuestos nacionales ms bajos, particularmente a pases en frica. Sin embargo, la inversin pblica es ms alta en pases ms ricos y ms baja en pases con las tasas ms altas de mortalidad por malaria. Las bajas tasas de gasto nacional en pases con la mayor carga de la enfermedad se deben principalmente a que estos pases tienen menos ingresos per cpita. 7. Existe variacin en la prioridad que se le da al control de la malaria por parte de los gobiernos que tienen similares niveles de disponibilidad de recursos. Los pases que tienen un mayor compromiso medido mediante el ndice de prioridades de inversin nacional mostraron ms xito en reducir la incidencia de casos de malaria entre 2000 y 2012 que lo que mostraron los otros pases.

malaria aument de 6 millones a 145 millones. Sin embargo, en 2011 los fabricantes entregaron solo 92 millones de MTI y en 2012 solo 70 millones. El nmero estimado de MTI entregados en 2013 (136 millones) y los nanciados por donantes para el 2014 (aproximadamente 200 millones) estn cerca del nmero de MTI que se requieren anualmente para proteger a todas las poblaciones en riesgo. Sin embargo, inclusive con el aumento en las entregas anuales, el total de MTI entregados en 2012-2014 (400 millones) para el periodo de 3 aos, todava estar por debajo del nmero mnimo que se necesita para proteger a todas las personas en riesgo de malaria. Es necesario mantener el nmero adecuado de entregas de MTI cada ao para asegurar su disponibilidad en las viviendas y que cada persona en riesgo de malaria tenga acceso a un MTI. 10. Se estima que el porcentaje de viviendas que poseen al menos un MTI en la regin de frica subsahariana aument de 3% en 2000 a 56% en 2012, pero disminuy ligeramente a 54% en 2013. La proporcin de la poblacin con acceso a MTI en sus viviendas aument durante el mismo periodo, alcanzando 42% en 2013. En 2013 se estim que la proporcin de la poblacin que duerme bajo un MTI que representa a la poblacin protegida de forma directa- fue de 36%. 11. Una comparacin entre la proporcin de la poblacin con acceso a un MTI y la proporcin que duerme bajo un MTI sugiere que un gran porcentaje (86%) de la poblacin con acceso a un MTI realmente lo utiliza, lo que indica que los esfuerzos por promover el uso de los MTI han tenido xito. La principal limitacin para aumentar el nmero de personas en riesgo que duermen bajo un MTI es la falta de disponibilidad de los mosquiteros. 12. El uso de MTI entre poblaciones vulnerables, mujeres embarazadas y nios menores de 5 aos de edad es mayor que el uso entre la poblacin total. Esto indica que estos grupos permanecen protegidos a medida que los pases mejoran la cobertura universal con MTI, y pone en evidencia la necesidad de aumentar el acceso a los MTI entre todas las personas en riesgo.

Rociado residual intradomiciliario

Avances en el control vectorial

En la regin de frica subsahariana, la proporcin de la poblacin con acceso a MTI en sus viviendas aument dramticamente de 2005 a 2011 pero se estabiliz en los ltimos 2 aos, alcanzando un 42% en 2013. Un aumento en la entrega de MTI durante los prximos 2 aos debera aumentar la cobertura de MTI.

13. El RRI contina siendo una herramienta poderosa para el control vectorial, reduciendo e interrumpiendo la transmisin de la malaria. En 2012, 88 pases recomendaron el RRI para el control de la malaria, incluyendo 40 pases en la regin africana. 14. En 2012, 135 millones de personas (4% de la poblacin mundial en riesgo de contraer malaria) alrededor del mundo se protegieron mediante el RRI. En frica, la proporcin de la poblacin en riesgo que se protegi se elev de menos del 5% en 2005 al 11% en 2010, pero disminuy a 8% en 2012, con 58 millones de personas benecindose con la intervencin. La disminucin en el nmero de personas protegidas mediante el RRI en frica parece deberse a un aumento en el uso de insecticidas no piretroides, ms costosos (en respuesta a la amenaza de la resistencia a insecticidas) en un contexto de presupuestos limitados para el RRI. El uso de insecticidas no piretroides para el RRI puede ir adquiriendo importancia como herramienta para el manejo de la resistencia, porque todos los MILD aprobados en la actualidad tienen como base los piretroides.

Mosquiteros tratados con insecticida

8. Para 2012, 34 pases en la regin africana y 83 pases de todo el mundo adoptaron la recomendacin de la OMS de proveer de MTI a todas las personas en riesgo de contraer malaria. Un total de 88 pases, incluyendo 39 en frica, distribuyen MTI de forma gratuita. 9. Se necesitan al menos 150 millones de MTI al ao para mantener el suministro de 450 millones de MTI en las viviendas por cada periodo de 3 aos y proteger a todas las poblaciones que estn en riesgo de malaria en la regin de frica subsahariana. Entre 2004 y 2010, el nmero de MTI que entregaron los fabricantes al ao a pases endmicos para
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Resistencia a insecticidas
15. En 64 pases endmicos alrededor del mundo se ha identicado resistencia de los mosquitos al menos a un insecticida utilizado para el control de la malaria. En mayo del 2012, la OMS y la alianza RBM publicaron el Plan Global para el Manejo de la Resistencia a Insecticidas (GPIRM, por sus siglas en ingls) en los vectores de la malaria; el GPIRM es una estrategia basada en cinco pilares para el manejo la amenaza de la resistencia a los insecticidas. Las partes interesadas de la comunidad mundial contra la malaria han iniciado actividades relacionadas con la implementacin de la estrategia plasmada en el GPIRM. 16. El monitoreo de la resistencia a los insecticidas es un elemento necesario para la implementacin de intervenciones basadas en insecticidas para el control vectorial. En 2012, 58 pases reportaron haber adoptado una poltica de monitoreo rutinario de la resistencia a insecticidas.

de la APN). Esto indica que la capacidad de proveer servicios preventivos durante las visitas de APN es alta, y que es posible superar las barreras para el TPIe. 21. Todos los nios menores de un ao en riesgo de infeccin por Plasmodium falciparum en los pases de la regin de frica subsahariana con transmisin moderada a alta de malaria y con bajos niveles de resistencia parasitaria a sulfadoxina-pirimetamina (SP) deberan recibir tratamiento preventivo para malaria a travs de los servicios de inmunizacin a intervalos denidos que correspondan con los esquemas de vacunacin rutinaria. Solo un pas, Burkina Faso, ha adoptado una poltica nacional de TPI para nios menores de un ao (TPIn) desde que la OMS emiti la recomendacin en 2009. 22. En marzo de 2012, la OMS emiti una recomendacin para SMC para nios de edades entre 3 a 59 meses, y en agosto de 2013, public una gua de campo para la implementacin de la SMC. Dos pases endmicos han adoptado la SMC, y varios pases que participan en la evaluacin de la poltica han indicado que tienen planeado adoptarla y expandir la cobertura de SMC ms all de sus poblaciones de estudio.

Progreso en quimioprevencin
Entre los pases africanos que reportan esta informacin a la OMS, en 2012 el porcentaje promedio de mujeres que acuden a atencin prenatal (APN) y que recibieron por lo menos una dosis de tratamiento preventivo intermitente (TPI) durante el embarazo fue de 64%, mientras que el 38% recibi por lo menos dos dosis y el 23% recibi por lo menos tres dosis, lo que indica que hay muchas posibilidades de mejorar la proteccin de las mujeres embarazadas. 17. En la regin de frica subsahariana, se estima que 35 millones de mujeres embarazadas y una gran parte de los 26 millones de nios que nacen cada ao se podran beneciar del TPI. Adems, alrededor de 25 millones de nios en la subregin africana de Sahel podra protegerse de contraer malaria a travs de la SMC. 18. Un total de 36 pases de frica subsahariana con transmisin moderada a alta de malaria adoptaron el TPI para mujeres embarazadas (TPIe) como una poltica nacional para nales del 2012. Esta poltica tambin fue adoptada por Papa Nueva Guinea (en la Regin del Pacco Occidental) en 2009. 19. En 26 de los 36 pases con transmisin moderada a alta de malaria en la regin africana que han adoptado el TPIe como una poltica nacional y para los que hay datos disponibles un promedio de 64% de las mujeres embarazadas que acuden a las APN recibieron al menos una dosis de TPIe en 2012, 38% recibieron al menos dos dosis y el 23% recibieron al menos tres dosis. En 13 pases de la regin africana para los cuales se contaba con datos de encuestas domiciliares para el perodo 2010-2012, el promedio ponderado de mujeres embarazadas que recibieron una dosis de TPIe durante el embarazo fue de 37%, mientras que el 23% recibi dos dosis y el 8% recibi tres dosis. 20. Desde octubre de 2012, la OMS ha recomendado que el TPIe se administre en cada una de las visitas prenatales calendarizadas despus del primer trimestre. El anlisis de los datos de encuestas domiciliares revela que la proporcin de mujeres embarazadas que recibieron TPIe est muy por debajo de la proporcin de las que asisten a APN. La proporcin de visitas de APN en las que se podra dar TPI pero no se da es alta, en un 72%. Menos mujeres reciben TPIe durante las visitas de APN que las que reciben toxoide tetnico (otro componente clave

Avances en la realizacin de pruebas diagnsticas y tratamiento de la malaria

El nmero de pruebas de diagnstico rpido (PDR) y TCA distribuidos est aumentando, al igual que la tasa reportada de pruebas de diagnstico en el sector pblico en la regin africana, que aument de 37% en 2010 a 61% en 2012. Como resultado ha disminuido el nmero de casos sospechosos de malaria que se trataron presuntivamente con medicamentos antimalricos. Sin embargo, a millones de personas con sospecha de malaria todava no se les realiza una prueba de diagnstico y mucha gente con infecciones conrmadas no recibe el tratamiento apropiado con un antimalrico de calidad garantizada.

Pruebas de diagnstico
23. La implementacin de la prueba diagnstica universal en los sectores pblico y privado reducira signicativamente los requerimientos mundiales de tratamiento antimalrico. En 2012, 41 de 44 pases con transmisin activa de malaria en la regin africana, y 49 de 55 pases en otras regiones de la OMS, reportaron haber adoptado una poltica para proporcionar diagnstico parasitolgico para todos los grupos de edad. Esto representa un aumento de 6 pases en la regin africana desde 2009. 24. Las pruebas de diagnstico para malaria se suministran sin costo en el sector pblico en 84 pases alrededor del mundo. En el periodo 2010 - 2012, la proporcin de casos sospechosos de malaria a los que se les practic una prueba de diagnstico en el sector pblico aument de 37% a 61% en la regin africana y de 44% a 64% a nivel mundial. La mayor parte del aumento en la realizacin de pruebas en la regin africana se debe al aumento del uso de PDR, que representaron el 40% de todos los casos evaluados en la regin en 2012. 25. El nmero de pacientes evaluados por medio de un examen microscpico se increment a hasta alcanzar un pico de 188 millones en 2012, de los cuales India contabiliz ms
WORLD MALARIA REPORT 2013 | xxv

de 120 millones de exmenes en extendidos de sangre. El nmero de PDR suministradas por los fabricantes aumentaron de 88 millones en 2010 a 205 millones en 2012. Esto incluye el aumento en las ventas de pruebas especcas para P. falciparum y pruebas combinadas que pueden detectar parsitos de ms de una especie. 26. 26. Un total de 48 pases reportaron la distribucin de PDR a nivel comunitario y 15 millones de pacientes reportaron haber sido evaluados a travs de esos programas en 2012. Los datos de encuestas domiciliares en 14 pases, recolectados durante el perodo 2010 2012, sugieren que las pruebas diagnsticas no estn ampliamente distribuidas en el sector privado como lo estn en el sector pblico. 27. 27. En los servicios de salud el uso de PDR para el diagnstico de los casos sospechosos de malaria ha aumentado, incluyendo el diagnstico de P. vivax. De los 42 pases que reportaron el tipo de PDR utilizadas, 15 reportaron el uso de PDR que pueden detectar P. vivax en especco. En estos pases, la proporcin de casos de P. vivax conrmados mediante PDR (en vez de microscopa) fue similar a la proporcin de casos de P. falciparum conrmados mediante PDR.

control de la malaria (PNCM) con el nmero total de casos sospechosos (o sea tratados sin que se les realice la prueba) y conrmados (por microscopia o por PDR) de malaria por P. falciparum (ajustados de acuerdo a la integridad del reporte o estimados en situaciones en las que no se cuente con datos reportados). Esta proporcin vara en cada una de las regiones de la OMS, pero ha aumentado a lo largo del tiempo en la regin africana, donde alcanz el 60% en 2012. 31. En nueve pases de la regin Africana con ms de una encuesta domiciliar entre 2006 y 2012, la proporcin de nios con enfermedad febril a los que se les ha dado tratamiento antimalrico con TCA ha aumentado a lo largo del tiempo, tanto en el sector pblico como en el privado. En la mayora de encuestas recientes, la proporcin promedio de nios que recibieron una TCA entre los que recibieron tratamiento antimalrico, fue de 68%; sin embargo, debido a que una parte importante de nios no acuden a atencin por ebre, y no a todos los nios con sospecha de tener malaria se les realiza una prueba de diagnstico, la proporcin de nios con malaria que recibe una TCA posiblemente es mucho menor. En un anlisis de 26 encuestas domiciliares que se realizaron entre 2010-2012, y que utilizaron una PDR positiva entre nios febriles como una aproximacin a un diagnstico conrmatorio de malaria, la media de la proporcin de nios con malaria conrmada que recibieron TCA fue de 16% (rango, 1%-42%). Se necesita aumentar el acceso a la atencin de febriles, as como a pruebas de diagnstico apropiadas para asegurar que todos los pacientes con malaria reciban tratamiento rpido y efectivo. 32. En la regin africana, en 2012, el nmero total de pruebas (tanto microscpicas como PDR) fue casi igual al nmero de TCA distribuidas por los PNCM una mayor razn en comparacin con aos anteriores. Sin embargo, en la mayora de reas endmicas para malaria, se espera que la razn sobrepase los 2, debido a que menos de la mitad de los casos sospechosos de malaria tendrn malaria conrmada y requerirn tratamiento con una TCA.

Tratamiento
28. Se recomienda las TCA como primera lnea de tratamiento de la malaria por P. falciparum, el ms peligroso de los parsitos de Plasmodium que infecta a seres humanos. Para 2012, 79 pases y territorios haban adoptado la TCA como primera lnea de tratamiento para la malaria por P. falciparum. La malaria por P. vivax debe ser tratada con cloroquina en los lugares donde el medicamento todava es efectivo, o por una TCA apropiada en reas donde P. vivax es resistente a cloroquina. El tratamiento de P. vivax se debe combinar con un rgimen de 14 das de primaquina para evitar recadas. 29. De los reportes de los fabricantes y de la iniciativa para Medicamentos Accesibles contra la Malaria (AMFm, por sus siglas en ingls), el nmero de tratamientos con TCA entregados en los sectores pblico y privado aument de 11 millones a nivel mundial en 2005 a 76 millones en 2006, y alcanz los 331 millones en 2012. El aumento en la adquisicin de TCA en 2012 se debi principalmente a un aumento de cerca del 50% en las entregas en el sector pblico entre 2011 y 2012. Los medicamentos adquiridos para el sector pblico y privado a travs de la iniciativa AMFm que se encuentra en estos momentos en una fase transitoria hacia una eventual integracin al proceso de concesin de subvenciones del Fondo Mundial para la Lucha contra el SIDA, Tuberculosis y Malaria (Fondo Mundial) - disminuyeron ligeramente de 156 millones de tratamientos en 2001 a 150 millones en 2012. 30. Ha sido difcil determinar hasta qu punto los pacientes con malaria conrmada han recibido tratamiento antimalrico, debido a que la informacin que vincula las pruebas de diagnstico con el tratamiento ha sido limitada tanto en encuestas domiciliares como en los sistemas regulares de informacin en salud. Si no se cuenta con datos reportados, se puede hacer un estimado de la proporcin de pacientes en el sector pblico que posiblemente han sido tratados con TCA (en lugar de un antimalrico menos efectivo) comparando el nmero de TCA distribuidas por los programas nacionales de
xxvi | WORLD MALARIA REPORT 2013

Resistencia de los medicamentos antimalricos

33. La OMS recomienda que el tratamiento oral con monoterapias basadas en artemisinina se vaya eliminando progresivamente del mercado y se reemplace con TCA una poltica que fue aprobada por la Asamblea Mundial de la Salud en 2007. El nmero de pases que todava permiten la comercializacin de estos productos disminuy de 55 en 2008 a 9 para noviembre de 2013; 6 de esos 9 pases estn en la regin africana. El nmero de compaas farmacuticas que comercializan estos productos decay de 38 en 2010 a 30 en 2013. Muchos de los pases que permiten la comercializacin de estos medicamentos estn en la regin africana, mientras que la mayora de fabricantes estn en la India. 34. Los estudios de ecacia teraputica siguen siendo el mtodo de referencia para guiar la poltica de medicamentos; ese tipo de estudios deben realizarse cada 2 aos. En 2011 y 2012, se completaron estudios de antimalricos de primera y segunda lnea de tratamiento en 48 de 67 (72%) pases donde fue posible realizar estudios de ecacia para P. falciparum un aumento de 31 de 75 (41%) pases durante el periodo 20082009. (En 32 pases con transmisin activa de malaria es imposibles realizar estudios de ecacia actualmente, debido a la

baja incidencia de malaria, o porque los pases son endmicos solamente para P. vivax). 35. Actualmente se ha detectado resistencia de los parsitos a las artemisininas en cuatro pases de la subregin del Gran Mekong: Camboya, Myanmar, Tailandia y Vietnam. A pesar de los cambios observados en la sensibilidad de los parsitos a las artemisininas, las TCA continan curando a los pacientes, toda vez que el medicamento combinado todava sea ecaz. En la provincia de Pailin en Camboya, se ha encontrado resistencia a ambos componentes de mltiples TCA, por lo tanto, se han puesto en prctica disposiciones especiales para la terapia de observacin directa usando una combinacin que no se basa en la artemisinina (atovacuona-proguanil). En abril del 2013, la OMS public la Respuesta de emergencia a la resistencia a la artemisinina en la subregin del Gran Mekong: Marco de trabajo regional para 2013-2015. El documento describe las reas prioritarias en las que se necesitan acciones en los prximos aos para frenar la resistencia a las artemisininas.

tratamiento de la malaria un hallazgo que necesita cambiar si se quiere continuar progresando hacia la realizacin universal de pruebas de diagnstico. El nmero de encuestas en las que se midi la prevalencia de parsitos ha aumentado desde 2005, elevndose a 81% de todas las encuestas realizadas entre 2011 y 2013.

Impacto en el control de la malaria

Desde el ao 2000, ms de la mitad de los pases que tuvieron una transmisin activa de malaria ese ao han registrado una disminucin en la incidencia de casos conrmados de malaria, o en ingresos y muertes (o ambas) reportadas. Las tasas estimadas de mortalidad por malaria en el mundo decayeron en un 45% entre 2000 y 2012 en todos los grupos de edad y en un 51% en nios menores de 5 aos de edad. Si se mantiene la tasa de disminucin de los ltimos 12 aos, se proyecta que las tasas de mortalidad por malaria disminuirn en 56% en todas las edades y en 63% en nios menores de 5 aos de edad para 2015. 38. En 2012 un estimado de 3.4 miles de millones de personas estuvieron en riesgo de contraer malaria. De este total, 2.2 mil millones en regiones de bajo riesgo (<1 caso reportado por 1000 habitantes), y de estos el 94% viviendo en otras regiones geogrcas fuera de frica. Los 1.2 mil millones de personas en regiones de mayor riesgo (>1 caso por cada 1000 habitantes) se encontraban principalmente en la regin africana (47%) y en Asia suroriental (37%). 39. En base a los datos reportados, 59 de 103 pases con transmisin activa de malaria en el 2000 estn alcanzando el ODM de reducir la incidencia de malaria. De estos, 52 estn en camino de alcanzar las metas de la iniciativa RBM y la Asamblea Mundial de la Salud de reducir la tasa de incidencia de casos de malaria en 75% para 2015, incluyendo 8 pases de la regin africana. 40. En promedio, las disminuciones en la incidencia de malaria por P. falciparum son mayores que las de P. vivax, lo cual sugiere que P. vivax responde ms lentamente a las medidas de control, posiblemente por sus caractersticas biolgicas. Como resultado, los PNCM necesitan dar mayor atencin al control de P. vivax a medida que se van acercando a la eliminacin, particularmente en reas fuera de frica subsahariana. En los pases donde se transmiten ambas especies, P. vivax predomina en los pases que estn en fase de pre-eliminacin y eliminacin. 41. De los 97 pases con transmisin activa de malaria en 2013, 12 se clasican en la fase de pre-eliminacin y otros 7 en fase de eliminacin. Otros 6 pases se clasican en la fase de prevencin de la introduccin. En 2012, se reportaron solo 255 casos autctonos en la regin europea; por lo que est cerca de alcanzar la meta de eliminar la malaria de la regin para 2015, como se plasm en la Declaracin de Tashkent del 2005. No obstante, los brotes recientes en Grecia y Turqua ponen de maniesto el riesgo permanente de reintroduccin y la necesidad de una vigilancia continua para asegurar que cualquier resurgimiento se controle rpidamente. 42. Los 52 pases que se proyecta (en base a los datos reportados) que disminuyan la incidencia de malaria en un 75% para el ao 2015, representan solamente 8 millones (4%) del total de 226 millones de casos estimados en el 2000. Esto se debe en
WORLD MALARIA REPORT 2013 | xxvii

Vigilancia, monitoreo y evaluacin de la malaria

En 2012, en 62 de 103 pases que tuvieron una transmisin activa de malaria en el 2000, el reporte de datos se consider sucientemente consistente como para emitir juicios conables acerca de las tendencias de la malaria para el periodo 2000-2012. En los 41 pases restantes, que aportan el 80% de los casos estimados, no es posible evaluar de forma conable las tendencias de la malaria utilizando los datos presentados a la OMS. Los sistemas de informacin son ms dbiles, y los retos para fortalecerlos son mayores, donde la carga de malaria es mayor. 36. En 2012, los sistemas rutinarios de informacin en salud detectaron solo el 14% de los casos que se estim que ocurriran a nivel mundial. Las tasas de deteccin de casos fueron menores en pases con el nmero ms alto de casos de malaria. De forma similar, la proporcin de muertes que se reportan fue la ms baja en pases con el mayor nmero de muertes por malaria. No es necesario que los sistemas de vigilancia detecten todos los casos para poder evaluar tendencias de forma conable; sin embargo, los esfuerzos para la deteccin de casos s deben ser razonablemente uniformes a lo largo del tiempo. Los pases con un menor nmero de casos estimados de malaria parecen ser los ms capaces de evaluar las tendencias en la incidencia. En los 41 pases que representaron el 80% de los casos estimados en el 2000, no se puede evaluar de forma conable las tendencias de la malaria para el periodo 2000-2012 utilizando los datos presentados a la OMS. Por esto, los sistemas de informacin son ms dbiles donde la carga por malaria es mayor. 37. En contraste con los datos reportados de forma rutinaria, las encuestas domiciliares se realizan ms comnmente en pases con el mayor nmero de casos de malaria. Cincuenta pases, de los cuales 34 fueron en la regin africana, realizaron al menos una encuesta domiciliar a lo largo del perodo de tres aos entre 2011-2013. Los indicadores que se midieron ms comnmente fueron sobre la disponibilidad de MTI y el uso de medicamentos antimalricos. Solo el 25% de las encuestas incluy preguntas sobre casos de ebre a los que se les practic un pinchazo en el dedo o en el taln, mientras que el 90% indag respecto al

parte a que el progreso ha sido ms rpido en los pases con un menor nmero de casos, pero tambin a la baja calidad de los datos de vigilancia presentados por los pases con mayor nmero de casos. Es esencial una mejor vigilancia y evaluacin en los pases con mayores cargas de malaria para poder evaluar adecuadamente el impacto de las inversiones en malaria. 43. Debido a que es menos probable que los pases con el mayor nmero de casos enven datos sucientemente consistentes como para evaluar las tendencias, es necesario sacar conclusiones en base a las tendencias en estos pases utilizando nmeros estimados de casos, en lugar de datos de vigilancia. En 2012 hubo un estimado de 207 millones de casos de malaria en el mundo (intervalo de incertidumbre 135-287). La mayora de los casos estimados (80%) ocurrieron en frica subsahariana. Alrededor de 9% de los casos estimados a nivel mundial se deben a P. vivax, a pesar que la proporcin fuera del continente africano es del 50%. Entre 2000 y 2012, la incidencia estimada de malaria disminuy en un 29% a nivel mundial y en un 31% en la regin africana. Si se mantiene la tasa anual de reduccin de los ltimos 12 aos, se espera que la incidencia de casos de malaria disminuya en un 36% a nivel mundial y en 40% en la regin africana para 2015. 44. En 2012 hubo un estimado de 627 000 muertes por malaria en el mundo (intervalo de incertidumbre 473 000 - 789 000). De las muertes estimadas, la mayora ocurrieron en frica subsahariana (90%) en nios menores de 5 aos de edad (77%). Entre 2000 y 2012, las tasas de mortalidad estimada por malaria disminuyeron en un 45% a nivel mundial y en 49% en la regin africana; se estima que disminuyeron en 51% en nios menores de 5 aos de edad a nivel mundial y en un 54% en la regin africana. Si se mantiene la tasa anual de reduccin de los ltimos 12 aos, se espera que las tasas de mortalidad por malaria disminuyan en un 61% a nivel mundial y en un 66% en la regin africana para 2015. En nios menores de 5 aos, se espera que para 2015 disminuyan en 63% a nivel mundial y en 68% en la regin africana. 45. El ritmo de la disminucin de las tasas estimadas de mortalidad por malaria se aceler a partir del 2005, pero se desaceler entre 2011 y 2012. Esta desaceleracin se debe en parte a que el modelo que se utiliza para estimar las muertes por malaria en nios menores de 5 aos de edad en frica utiliza la cobertura de MTI para ajustar la proporcin de muertes atri-

buidas a la malaria, y la cobertura de MTI se estanc en 20112012 luego de las disminuciones en el nanciamiento para el control de la malaria en 2011. 46. Ms del 80% de las muertes estimadas por malaria en 2012 ocurrieron en solo 17 pases, y el 80% de los casos de malaria ocurrieron en 18 pases, con la Repblica Democrtica del Congo y Nigeria aportando juntos el 40% del estimado total a nivel mundial. Las metas para la reduccin de casos y muertes no podrn alcanzarse hasta que se realice un progreso signicativo en los pases que aportan la mayor carga por malaria. 47. Cuatro pases aportan ms del 80% de casos estimados de malaria por P. vivax (Etiopa, India, Indonesia y Paquistn). La infeccin por P. vivax se ha asociado con malaria severa y muerte, a pesar que los riesgos de enfermedad severa y las tasas de fatalidad por infecciones con P. vivax no se han establecido en denitiva. Se sospecha que la presencia de co-morbilidades, en particular la malnutricin concomitante, aumentan el riesgo de enfermedad severa en infecciones por P. vivax, aunque este riesgo tambin permanece mal denido. Se requieren ms estudios para renar los conocimientos existentes sobre la malaria severa por P. vivax, y de los riesgos de enfermedad severa y muerte con esta infeccin. 48. El avance en la reduccin de las tasas de incidencia de casos y mortalidad por malaria ha sido ms rpido en los pases con el menor nmero de casos y muertes en 2000. Sin embargo, entre 2000 y 2012 la gran mayora del nmero de casos y muertes se evitaron en pases que tuvieron las mayores cargas por malaria en el ao 2000. Si las tasas de incidencia y mortalidad por malaria del 2000 se mantuvieron sin cambio a lo largo de la dcada, debieron haber ocurrido 500 millones ms de casos y 3.3 millones ms de muertes entre 2001 y 2012. La mayora de casos de malaria que se evitaron (67%) y vidas que se salvaron (93%) correspondieron a la regin africana. 49. De los 3.3 millones de muertes que se previnieron entre 2001 y 2012, se estima que 3 millones (90%) fueron en nios menores de 5 aos de edad en Africa subsahariana. Esto representa el 20% de las 15 millones de muertes en nios que se estima que han sido evitadas en Africa subsahariana desde el ao 2000 a travs de la reduccin general de las tasas de mortalidad infantil. Por lo tanto, la disminucin en las muertes por malaria ha contribuido sustancialmente al progreso hacia el logro de las metas del ODM 4 de reducir en dos terceras partes la tasa de mortalidad de menores de 5 aos entre 1990 y 2015.

xxviii | WORLD MALARIA REPORT 2013

CHAPTER 1

Introduction
This edition of the World Malaria Report summarizes the current status of malaria control worldwide. It reviews progress towards internationally agreed goals and targets, and describes trends in funding, intervention coverage and malaria cases and deaths. In 2013, there are 97 countries and territories with ongoing malaria transmission, and 7 countries in the prevention of reintroduction phase, making a total of 104 countries and territories in which malaria is presently considered endemic. Globally, an estimated 3.4 billion people are at risk of malaria. WHO estimates that 207 million cases of malaria occurred globally in 2012 (uncertainty range 135287 million) and 627 000 deaths (uncertainty range 473 000789 000) (Chapter 8; Section 8.3). Most cases (80%) and deaths (90%) occurred in Africa (Figure 1.1), and most deaths (77%) were in children under 5 years of age. Malaria is caused by ve species of parasite that aect humans, and all of these species belong to the genus Plasmodium: P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. Of these, P. falciparum and P. vivax are the most important. Malaria due to P. falciparum is the most deadly form, and it predominates in Africa. P. vivax has a wider distribution than P. falciparum because it is able to develop in the Anopheles mosquito vector at lower temperatures, and to survive at higher altitudes and in cooler climates. It also has a dormant liver stage (known as a hypnozoite) that enables it to survive during periods when Anopheles mosquitoes are not present to continue transmission, such as during winter months (Table 1.1). Although P. vivax can occur throughout Africa, the risk of P. vivax infection is considerably reduced in the region by the high frequency of the Duy negativity trait among many African populations; in individuals without the Duy antigen, red blood cells are resistant to infection with P. vivax. In many areas outside Africa, infections due to P. vivax are more common than those due to P. falciparum. Malaria is spread from one person to another by female mosquitoes of the genus Anopheles. There are about 400 dierent species of Anopheles mosquitoes, but only 30 of these are vectors of major importance. Malaria is an entirely preventable and treatable disease, provided the currently recommended interventions are properly implemented. These interventions include (i) vector control through the use of insecticide treated nets (ITNs), indoor residual spraying (IRS) and, in some specic settings, larval control; (ii) chemoprevention for the most vulnerable populations, particularly pregnant women and infants; (iii) conrmation of malaria diagnosis through microscopy or rapid diagnostic tests (RDTs) for every suspected case; and (iv) timely treatment with appropriate antimalarial medicines (according to the parasite species and any documented drug resistance). The World Malaria Report is a key publication of the WHO Global Malaria Programme (GMP), and over the years it has provided a
Table 1.1 Comparison of P. falciparum and P. vivax malaria
Life cycle P. falciparum P. vivax

Minimum temperature Lowest needed for maturation temperature 16c in the mosquito

For cycle to be complete lowest temperature 15c, survival of parasite to 10c for two days Yes Appear at time of asexual blood stage often before clinical symptoms Risk of severe disease not rmly established

Dormant liver stage Gametocytes

No Appear after asexual blood stage is established 5% of cases develop into severe illness; responsible for majority of deaths No Common

Disease Severity

Relapse Asymptomatic carriage Diagnosis

Yes Very common

Blood lm, rapid tests and PCR for blood stage

Blood lm, rapid tests and PCR for blood stage No test for dormant liver stage

Treatment Blood stage Artemisinin combination treatment (ACT) recommended Need single dose primaquine, artemesinins have some eect Chloroquine still ecacious in most areas Sensitive to blood stage treatment

Gametocytes

Liver stage

14 days of primaquine

historical record of the global malaria situation and the progress made through national and international eorts to control the disease. The GMP has four essential roles: (i) to set, communicate and promote the adoption of evidence-based norms, standards, policies and guidelines; (ii) to ensure ongoing independent assessment of global progress; (iii) to develop strategies for capacity-building, systems strengthening and surveillance; and (iv) to identify threats to malaria control and elimination, and new opportunities for action. The World Malaria Report presents a critical analysis and interpretation of data provided by national malaria control programmes
WORLD MALARIA REPORT 2013 | 1

(NMCPs) in endemic countries. Standard reporting forms were sent in April 2013 to the 97 countries with ongoing malaria transmission, and to 5 of the countries that recently entered the prevention of reintroduction phase. Information was requested on (i) populations at risk; (ii) vector species; (iii) number of cases, admissions and deaths for each parasite species; (iv) completeness of outpatient reporting; (v) policy implementation; (vi) commodities distributed and interventions undertaken; (vii) results of household surveys; and (viii) malaria nancing. Table 1.2 summarizes the percentage of countries responding by month and by WHO region in 2012. Information from household surveys was used to complement data submitted by NMCPs, notably the demographic and health surveys (DHS), multiple indicator cluster surveys (MICS) and malaria indicator surveys (MIS). These surveys provide information on the percentage of the population that sleeps under a mosquito net, and the percentage of children with fever who are treated and the medication they receive. Information on malaria nancing was obtained from the Organisation for Economic Co-operation and Development (OECD) database on foreign aid ows, and directly from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the US Presidents Malaria Initiative (PMI). Data were analysed by WHO sta at headquarters and regional oces, with extensive consultation with WHO country oces and NMCPs regarding the interpretation of country information. Assistance in data analysis and interpretation was also provided by the African Leaders Malaria Alliance (ALMA), the Child Health Epidemiology Reference Group (CHERG), the Institute of Health Metrics and Evaluation (IHME), the London School of Hygiene and Tropical Medicine, the Malaria Atlas Project (MAP), Tulane University School of Public Health and Tropical Medicine, the US Centers for Disease Control and Prevention (CDC) and the Global Fund. The following chapters consider the policies and interventions recommended by WHO, the implementation of interventions, and the impact of these interventions on malaria cases and deaths, from a global and a regional perspective. Chapter 2 summarizes the WHO policy-setting process and the policies and strategies recommended by WHO to achieve the internationally agreed goals for malaria control and elimination. It describes the goals and targets for malaria control and elimination, and recommended indicators of progress. Chapter 3 reviews recent trends in international and domestic nancing in relation to the resource requirements for meeting global malaria control targets. It examines the distribution of

malaria funding by WHO region, by gross national income (GNI) per capita and by malaria mortality rate of a country. It also reviews endemic countries willingness to pay for malaria control. Chapter 4 reviews the commodity needs for malaria vector control. It considers the policies that national programmes have adopted for vector control implementation, and the progress made towards universal access to ITNs and IRS. An update is provided on the growing problem of insecticide resistance, and the appropriate monitoring and management of resistance. Chapter 5 reviews progress in implementation of chemoprevention, particularly the intermittent preventive treatment of malaria in pregnancy and in infants, and the introduction of seasonal chemoprevention in older children. It also reports on the current status of malaria vaccine development. Chapter 6 reviews the commodity needs for malaria diagnostic testing and treatment. It reports on the extent to which national programmes have adopted policies for universal diagnostic testing of suspected malaria cases, and examines trends in the availability of parasitological testing. It also reviews the adoption of policies and implementation of programmes for improving access to eective treatment for malaria. Finally, this chapter reports on progress in the withdrawal of oral artemisinin-based monotherapies from the market, the current status of drug ecacy monitoring, recent trends in antimalarial drug resistance and eorts to contain artemisinin resistance. Chapter 7 examines the extent to which data are available for monitoring progress towards international targets, and how this has changed since 2000. Chapter 8 reviews trends in reported malaria cases for 62 countries that have reported consistently between 2000 and 2012. For countries with low numbers of cases, it summarizes their progress towards elimination. This chapter also presents an analysis of the estimated numbers of cases and deaths for countries with ongoing transmission between 2000 and 2012. Regional proles are provided. These summarize the epidemiology of malaria in each WHO region, trends in malaria case incidence, and the links between malaria trends and malaria programme implementation. Country proles are also provided for countries with ongoing malaria transmission and those recently progressing to the prevention of reintroduction phase. These proles are followed by Annexes, which give data by country for the malaria-related indicators.

Table 1.2 Percentage of reporting forms received by month and by WHO region, 2012
WHO region June July August September October November December Total countries/areas

African Eastern Mediterranean European Regions of the Americas South-East Asia Western Pacic TOTAL 60% 6% 20% 90% 17% 10% 83%

91% 50% 83% 20% 90% 62%

98% 90% 83% 95% 80% 100% 94%

98% 100% 83% 100% 100% 100% 98%

100% 100% 83% 100% 100% 100% 99%

100% 100% 100% 100% 100% 100% 100%

45 10 6 21 10 10 102

Source: : National malaria control programme reports 2 | WORLD MALARIA REPORT 2013

CHAPTER 2

Policies, strategies, goals and targets for malaria control and elimination
This chapter summarizes (i) the policy-setting process within WHO, (ii) the policies and strategies recommended by WHO to achieve the internationally agreed goals for malaria control and elimination, (iii) the need for malaria surveillance systems, and (iv) indicators of progress.

Box 2.1 New or updated WHO policies, operational manuals, guidelines and strategies for malaria control and elimination in 2013
Updated Policies WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control, September 2013 Operational manuals, handbooks and guidelines Management of severe malaria A practical handbook. Third edition, April 2013 (2) Indoor residual spraying: An operational manual for IRS for malaria transmission, control and elimination, April 2013 (3) Test procedures for insecticide resistance monitoring in malaria vector mosquitoes, April 2013 (4) Larval source management a supplementary measure for malaria vector control. An operational manual, July 2013 (5) Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine in children: A eld guide, August 2013 (6) Malaria control in humanitarian emergencies An inter-agency eld handbook. Second edition, October 2013 (7) Strategies, Action Plans and Initiatives Emergency response to artemisinin resistance in the Greater Mekong subregion. Regional Framework for Action 20132015, April 2013 (8) Guidance notes WHO guidance note on estimating the longevity of long-lasting insecticidal nets in malaria control, September 2013 (9) WHO guidance note on capacity building in malaria entomology and vector control, September 2013 (10) Training manuals Training module on malaria control: Case management, August 2013 (11) Training module on malaria control: Entomology and vector control, August 2013 (12) Training module on malaria control: Epidemiological approaches, November 2013 (13)
headquarters, regional oces and country oces. The documents are also made accessible through a single web portal.1

2.1 Policy development

Following a comprehensive review of its policy-setting process on malaria, WHO established an independent advisory committee in 2011, bringing together some of the worlds foremost experts on malaria. Since its inaugural meeting in January 2012, the Malaria Policy Advisory Committee (MPAC) has provided strategic technical advice to WHO on the development of policy guidance on malaria control and elimination. The MPAC is supported by technical expert groups and evidence review groups, whose work focuses on specic thematic areas (see Box 2.2). The MPAC advises WHO on:

appropriate malaria policies and standards (based on data from malaria programme implementation by member states and malaria control partners, and on reviews of the best available evidence); WHOs engagement in malaria-related initiatives; major issues and challenges in achieving global malaria goals; the identication of priority activities to address identied challenges.

The MPAC meets twice a year in March and September and its expert groups meet throughout the year, as necessary. To each MPAC meeting, WHO invites four standing observers (Global Fund to Fight AIDS, Tuberculosis and Malaria; Roll Back Malaria [RBM] Partnership; United Nations Childrens Fund [UNICEF]; and the Oce of the United Nations SecretaryGenerals Special Envoy for Financing the Health Millennium Development Goals and for Malaria). Also invited on a rotational basis are seven national malaria control programme (NMCP) managers, covering all WHO regions. In addition, the meetings are open to any member of the global malaria community who registers. Observers can make interventions at the invitation of the chair. MPAC decisions are taken in closed session and are agreed by consensus. MPAC conclusions and meeting reports are published on the WHO website and in the Malaria Journal as part of the WHO global malaria recommendations series (1). Following MPAC deliberations, new and updated policy guidance documents are formally issued by WHO and are disseminated to member states by three levels of the organization

1. http://www.who.int/malaria/publications/en/ WORLD MALARIA REPORT 2013 | 3

Box 2.2 Malaria Policy Advisory Committee structure in 2013

The 15 members of the MPAC serve in an independent, personal and individual capacity, representing a broad range of disciplines, expertise and experience.2 During 2013, MPAC received advice from ve technical expert groups and two evidence review groups. Technical expert groups Technical expert groups are standing expert groups that meet regularly to review evidence on specic intervention areas and provide continuous technical support to MPAC. In 2013, the following groups operated under the MPAC umbrella: Technical Expert Group on Antimalarial Drug Resistance and Containment Technical Expert Group on Malaria Chemotherapy Technical Expert Group on Malaria Vector Control Vector Control Advisory Group (VCAG) on New Tools jointly managed by the Global Malaria Programme and the Department of Neglected Tropical Diseases Joint Technical Expert Group (JTEG) on Malaria Vaccines Entering Pivotal Phase 3 Trials & Beyond jointly managed by the Department for Immunization, Vaccines & Biologicals and the Global Malaria Programme Evidence review groups Evidence review groups are expert groups convened for a limited time to review a specic area of work, and to provide evidence-based options for recommendations. In 2013, the following groups operated under the MPAC umbrella: Evidence Review Group on Malaria Burden Estimation Methodology Evidence Review Group on Intermittent Preventive Treatment in Pregnancy

coverage with long-lasting insecticidal nets (LLINs), estimating the durability of LLINs, and capacity building for entomologists. In addition, the MPAC was briefed on the following topics: the vaccine candidate RTS,S/AS01; the malaria vaccine technology roadmap; the availability of nancial resources for malaria control; the use of diagnostics in low-transmission settings; the use of glucose-6-phosphate dehydrogenase (G6PD) deciency tests; the Global Strategic Plan for P. vivax Control and Elimination (see Box 2.5); the Global Technical Strategy for Malaria Control and Elimination 20162025 (see Box 2.3); and methods and channels for the global dissemination of WHO policy guidance.

2.2 Malaria control policies and strategies

WHO recommends a multi-pronged strategy to control and eliminate malaria, which includes vector control interventions, preventive therapies, diagnostic testing, treatment with quality-assured artemisinin-based combination therapies (ACTs), and strong malaria surveillance. Eective malaria control and elimination requires strong and well-funded NMCPs, tailored national and regional strategies, extensive applied and operational research, and a close collaboration among partners in the global malaria and development community. Achieving eective scale-up of malaria interventions also requires signicant human resources at national, district and community levels, and the regular training of malaria programme sta.

2.2.1 Malaria prevention through vector control

The goals of malaria vector control are to: reduce human-vector contact and protect individuals from mosquitoes that carry malaria-causing parasites; lower the intensity of malaria transmission at community level by reducing the average lifespan of the local mosquito population.

Hardcopies of documents are sent directly to NMCP and global malaria partners, and are available during the World Health Assembly and Regional Committee meetings, high-level scientic and intergovernmental conferences, and technical workshops. WHO also collaborates with the RBM Partnership in disseminating guidance documents to a broader audience. In addition, some key documents can be purchased through the WHO online bookshop. 3 The two 2013 sessions of the MPAC focused on the following themes: artemisinin resistance containment in the Greater Mekong subregion; artemisinin ecacy in Guyana and Suriname; management of febrile illnesses in peripheral health settings; intermittent preventive treatment in pregnancy; the process for updating the malaria treatment guidelines; harmonization of methods for estimating the global malaria burden; elimination criteria and classication; surveillance, monitoring and evaluation; and a range of vector control issues including achieving universal
2. For more information about MPAC and its members, please visit the MPAC home page: http://www.who.int/malaria/mpac/en/ 3. http://apps.who.int/bookorders/ 4 | WORLD MALARIA REPORT 2013

Insecticide-treated mosquito nets (ITNs) which include both LLINs and conventional nets treated with an insecticide work both on the individual level (by protecting the person sleeping under the net) and the community level (by extending the eect to an entire area). WHO recommends universal coverage of at-risk populations with ITNs, and urges a switch-over to LLINs. Given that the vast majority of nets being procured and distributed today are LLINs, the remainder of this section focuses on LLINs. IRS involves the application of residual insecticides to the inner surfaces of dwellings targeting Anopheles mosquitoes that rest on walls after having taken a blood meal. IRS programmes can rapidly reduce local malaria incidence and mortality, provided that most houses and animal shelters in targeted communities are sprayed. WHO recommends the spraying of at least 80% (and ideally 100%) of houses, structures and units in the targeted area in any round of spraying (3). Achieving universal coverage with eective vector control interventions requires timely and sustained programme-delivery operations. In turn, this requires specialized personnel at national, provincial, district and community levels. These teams

Box 2.3 Global Technical Strategy for Malaria Control and Elimination 20162025
Following a request by the MPAC in 2012, WHO began coordinating the development of a Global Technical Strategy for Malaria Control and Elimination for the period 20162025. This global strategy will provide member states with updated, comprehensive and evidence-based technical guidance for accelerated action to control and eliminate malaria (covering all intervention areas), and for setting strategic directions and targets beyond 2015. This work is underpinned by a review of existing country and regional strategies, as well as broad-based technical consultations across all WHO regions. Oversight is provided by the MPAC, and the strategy development process is led by a steering committee that brings together leading scientists, technical experts and representatives of endemic countries. The Global Technical Strategy is being developed in close collaboration with the RBM Partnerships Global Malaria Action Plan (GMAP) II, which will focus on global advocacy, resource mobilization, partner harmonization, the engagement of non-health sectors, and global, regional and country-level planning for the implementation of the Global Technical Strategy. The steering committee for the WHO process and the taskforce for the RBM process have overlapping membership, to ensure alignment and coordination. In the course of 2014, WHO and RBM will hold back-to-back regional consultations. Timelines During the 2013 World Health Assembly, member states expressed support for the development of the Global Technical Strategy for Malaria Control and Elimination 20162025. Following endorsement by the MPAC in autumn 2014, the strategy will be submitted to the WHO Executive Board and presented to member states for consideration during the 2015 World Health Assembly. The Global Technical Strategy for Malaria Control and Elimination 20162025 and GMAP II are scheduled to be formally launched, as companion documents, in the second half of 2015.

is best achieved through free mass distribution campaigns every 3 years or less. However, to ensure that coverage is maintained, it is essential to complement these campaigns with continuous distribution programmes (e.g. through antenatal and routine immunization services) before, during and after mass campaigns. Further details can be found in WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control, issued in 2013 (15). Given that most countries are far from achieving universal LLIN coverage, improving access to LLINs should be the most important priority of distribution programmes. Evidence suggests that about 90% of the population with access to a mosquito net actually uses it. In areas where LLIN use is identied as being lower, WHO recommends the roll-out of behaviour-change communication programmes, including information, education and communication (IEC) campaigns (16). NMCPs and global malaria partners should only procure LLINs that have been recommended by the WHO Pesticide Evaluation Scheme (WHOPES). At present, 11 products are recommended by WHOPES (17). Independent quality control should be undertaken before shipment, and the cost of analysis should be borne by suppliers, including the cost of sending samples to an accredited or recognized laboratory for analysis on behalf of countries that do not have adequately equipped or staed national quality-control laboratories (18). Detailed guidance on good practices in the handling and use of products containing insecticides, and on quality control in procurement, can be found on the WHOPES website.4 The lifespan of LLINs depends greatly on the product type and the setting in which the products are used. Therefore, all large-scale LLIN programmes (including those implemented by nongovernmental organizations, NGOs) should monitor LLIN durability locally, in line with the WHO guidelines for monitoring the durability of LLINs under operational conditions (19), and refer to the WHO guidance note for estimating the longevity of long-lasting insecticidal nets in malaria control, issued in 2013 (9). The collection of local data on the comparative durability of LLIN products, using rigorous and auditable methods, would allow procurement decisions to be made on the basis of price per year of protection rather than unit price per net. This, in turn, would lead to substantial cost savings (20). Such savings are critical because LLINs represent a large proportion of NMCP budgets. Indoor residual spraying IRS is applicable in many epidemiological settings, provided that its operational and resource feasibility is considered in policy and programming decisions. IRS requires specialized spray equipment and techniques, and given the diculty of carrying out spray operations, it also requires scrupulous maintenance of the equipment, timing and quality of application, and monitoring and disposal capabilities. Currently, WHOPES recommends 12 insecticide compounds and formulations, belonging to four chemical classes, for deployment in indoor spraying programmes (21). An insecticide for IRS should be selected for a given area on the basis of community acceptance, data on insecticide resistance, the residual ecacy
4. http://who.int/whopes/quality/en WORLD MALARIA REPORT 2013 | 5

should have extensive practical experience, coupled with the capacity to monitor and evaluate vector-related and operational factors that may compromise intervention eectiveness. Hence, specialized entomological knowledge and skills are essential. Detailed recommendations for malaria vector control are as follows: Insecticide-treated nets To meet the target of universal access, WHO recommends that one LLIN be distributed for every two people at risk of malaria. Since many households have an odd number of members, the calculation needs to be adjusted when quantifying at the population level. For procurement purposes, WHO recommends using an overall ratio of one LLIN for every 1.8 persons in the target population (14). LLINs procured through public health funds should be provided free of charge to all populations at risk. Universal access to LLINs

of the insecticide, costs, safety and the type of surface to be sprayed. Detailed guidance on IRS is available in Indoor residual spraying: An operational manual for IRS for malaria transmission, control and elimination, released in 2013 (3). Dichlorodiphenyltrichloroethane (DDT) has a comparatively long residual ecacy (6 months) as an insecticide for IRS. The use of DDT in agriculture is banned under the Stockholm Convention on Persistent Organic Pollutants (eective as of May 2004). Nevertheless, countries can use DDT for IRS for as long as necessary and in the quantities needed provided that the guidelines and recommendations of WHO and the Stockholm Convention are all met until locally appropriate, cost-eective alternatives are available for a sustainable transition from DDT. Further details can be found in the 2011 WHO position statement on DDT (22) and in the decision adopted by the Conference of the Parties to the Stockholm Convention (23). Larval source management In a few specic settings and circumstances, the core interventions of LLINs and IRS may be supplemented by larval source management, which includes four subcategories: vector habitat modication, habitat manipulation, larviciding and biological control. Currently, WHOPES recommends 10 compounds and formulations for mosquito larval control (24). Detailed guidance on larval source management is available in Larval source management a supplementary measure for malaria vector control. An operational manual, released in 2013 (5). Larviciding the most widely used of larval source management approaches involves the regular application of a biological or chemical insecticide to water bodies to reduce the number of mosquito larvae and pupae. These interventions can be useful in urban and periurban areas, but they are unlikely to be eective in most areas of rural Africa, where mosquito breeding sites are generally innumerable, shifting and widely dispersed. WHO recommends larviciding only in settings where mosquito breeding sites are few, xed and ndable, and where sites are easy to identify, map and treat. WHO and partners should continue to work with endemic countries that choose to use larviciding, to ensure that such programmes are implemented and monitored appropriately. Further details can be found in the WHO interim position statement on larviciding, issued in 2012 (25).

stakeholders representing all constituencies, including malariaendemic countries, multilateral agencies, development partners, academia and industry. The strategy is based on ve pillars: plan and implement IRM strategies in malaria-endemic countries; ensure proper, timely entomological and resistance monitoring, and eective data management; develop new, innovative vector control tools; ll gaps in knowledge on mechanisms of insecticide resistance and the impact of current IRM strategies; and ensure that enabling mechanisms (advocacy, human and nancial resources) are in place. The GPIRM provides detailed technical recommendations on both monitoring and managing insecticide resistance in dierent settings, depending on the extent and mechanisms of insecticide resistance, and the type of vector control interventions used. Insecticide resistance management During the past 10 years, the main factor driving the emergence and spread of insecticide resistance has been the heavy reliance on a single class of insecticides: the pyrethroids. The pyrethroids are both highly eective and the least expensive of the four classes of insecticides available for public health vector control. Preserving the ecacy of pyrethroids is an urgent global priority, because pyrethroids are the only class of insecticide available for use on LLINs, and most new products and compounds are still years away from entering the market. WHO urges endemic countries to draw up comprehensive national IRM strategies and deploy them in a pre-emptive manner. Through IRM, countries can delay the evolution of resistance, preserve the eectiveness of existing insecticides, and possibly even reverse resistance in some settings. When programmatic decisions are taken, insecticide resistance or the potential for its development should be considered as being just as important as the cost-eectiveness of vector control programmes. For all settings, the GPIRM recommends that the operational impact of LLIN use be monitored closely, and that insecticide resistance be tested at sentinel sites at least once a year, and preferably every 6 months. The GPIRMs additional technical recommendations are divided into three main areas, according to the main vector control methods used in a specic geographical area where: IRS is the main form of vector control LLINS are the main form of vector control IRS and LLINs are used in combination. Each of these is discussed below. Where IRS is the main form of vector control National vector control programmes should annually rotate the insecticides used for IRS in order to preserve the eectiveness of current compounds. In places where this recommendation can only be implemented in stages, the rst priority should be to introduce rotations in areas of identied resistance and in those with the highest malaria transmission. The rotation systems may include the use of a pyrethroid.

2.2.2 Insecticide resistance

Anopheles mosquito resistance to insecticides has been detected in 64 countries with on-going malaria transmission, aecting all major vector species and all classes of insecticides (26). Current vector control tools remain eective; however, if left unchecked, insecticide resistance could lead to a substantial increase in malaria incidence and mortality. The global malaria community needs to take coordinated action to prevent insecticide resistance from emerging at new sites, and to urgently address it at the sites where it has been identied. In 2012, WHO issued the Global plan for insecticide resistance management in malaria vectors (GPIRM) (26), urging endemic countries to ensure timely entomological and resistance monitoring, and to develop and implement comprehensive insecticide resistance management (IRM) strategies. The GPIRM was developed through a broad-based consultation with over 130
6 | WORLD MALARIA REPORT 2013

Where LLINs are the main form of vector control In areas where LLINs are the main form of vector control, IRM strategies should be aligned with the perceived level of threat from resistance. This will depend on the nature and strength of resistance in the vector population, and on whether the number of conrmed malaria cases is rising. If countries do not have a surveillance system that can promptly detect an increase in malaria cases, this capacity must be established as a matter of urgency. Even in areas where resistance has been identied, LLINs continue to provide some level of protection by acting as a physical barrier against disease vectors. Countries should therefore continue to promote the goal of universal LLIN coverage. In areas with high levels of LLIN coverage in which pyrethroid resistance is identied, WHO recommends the deployment of focal IRS with a non-pyrethroid insecticide. The presence of a non-pyrethroid on wall surfaces reduces the probability that pyrethroid resistance will spread. The current product development pipeline indicates that combination LLINs (i.e. containing more than one insecticide) may become available in the short term (i.e. the next 24 years), and LLINs with new active ingredients may become available in the long term (i.e. the next 69 years). As soon as combination LLINs and non-pyrethroid LLINs become available and are recommended by WHO, control programmes should procure those for distribution. The WHO Vector Control Advisory Group (VCAG) on New Tools, established in 2013, is expected to shorten the process of getting new vector control tools and technologies approved and registered on a country level. Where IRS and LLINs are used in combination In areas where IRS and LLINs are used in combination, two pre-emptive actions are needed. First, in areas of high LLIN coverage, pyrethroids should not be used for IRS, because this will contribute to selection pressure. Instead, IRS should be conducted with alternative, non-pyrethroid insecticides. If possible, the alternative insecticides should be used in a rotation scheme to avoid the development of resistance to any one of them. Second, because continued use of LLINs is likely to contribute to selection pressure, countries should ensure frequent resistance monitoring, at least once a year and preferably every 6 months. In areas where pyrethroid resistance has been conrmed, vector control programmes should continue to scale up LLINs, and closely monitor their eectiveness through a combination of entomological monitoring data and epidemiological data from routine malaria surveillance. In areas of high malaria transmission, evidence is emerging that the use of IRS and LLINs in combination could be more eective than either intervention alone. WHO guidance on this topic is expected to be updated in 2014 through the Technical Expert Group on Malaria Vector Control and the MPAC. Resistance monitoring and testing Resistance monitoring should be seen as a critical element of any medium or large-scale deployment of an insecticidal intervention, and should be overseen and coordinated by NMCPs. It is the responsibility of implementing agencies to ensure that

testing is done properly and in collaboration with NMCPs. Donor organizations nancing procurement of vector control products that contain insecticides should ensure that product decisions are supported by adequate and up-to-date information on vector resistance. In each country, it is imperative to establish a national mechanism through which all data collected on vector resistance is analysed, interpreted, reported and shared for local procurement and policy decisions. This includes the establishment and management of national databases on insecticide resistance. In 2013, WHO released new guidance about recommended test procedures for insecticide resistance (4), including recommended equipment and supplies, and a detailed description of test conditions and protocols. The document contains recommendations on how susceptibility test results should be recorded and reported, including how mortality and knockdown rates should be calculated, how susceptibility test results should be interpreted, and how susceptibility testing results should be reported. Current testing procedures also include the bottle bioassay developed by the United States Centers for Disease Prevention and Control. Capacity building in entomology and vector control In the WHO guidance note on capacity building in malaria entomology and vector control, issued in 2013 (10), WHO urges endemic countries and global malaria partners to strengthen human capacities in entomology and vector control. The multifaceted challenges of vector control can only be tackled if countries possess a strong cadre of entomologists and oer the training, support structure and nancing that is needed to eectively plan, monitor, evaluate and manage vector control eorts.

2.2.3 Preventive chemotherapy

Preventive chemotherapy is the use of complete treatment courses of eective antimalarial medicines for targeted population groups at risk of malaria, with the goal of preventing malaria infection and thereby reducing malaria-related morbidity and mortality. The three preventive therapies presently recommended by WHO are intermittent preventive treatment in pregnancy (IPTp), intermittent preventive treatment in infants (IPTi), and seasonal malaria chemoprevention (SMC), each of which is discussed below. Intermittent preventive treatment in pregnancy (IPTp) Following a 2012 review of the evidence (27) and an assessment by the MPAC, WHO recommends IPTp with sulfadoxinepyrimethamine (SP) for all pregnant women at each scheduled antenatal care visit after the rst trimester, in areas of moderate to high malaria transmission in sub-Saharan Africa. The rst IPTp-SP dose should be administered as early as possible during the second trimester of pregnancy. Each SP dose should be given at least one month apart, and the last dose can be administered up to the time of delivery. Implementation guidance is provided through a WHO policy brief, released in 2013 (28). Recommended indicators for monitoring IPTp implementation have been updated (see Section 2.6 and Table 2.2). Intermittent preventive treatment in infants (IPTi) All infants at risk of Plasmodium falciparum infection in countries in sub-Saharan Africa with moderate to high malaria transmisWORLD MALARIA REPORT 2013 | 7

sion should receive a dose of SP along with the DPT2, DPT3 and measles vaccines (three doses in total) through the routine immunization programme (29). IPTi provides partial protection in the rst year of life against clinical malaria and anaemia, and reduces hospital admissions associated with malaria parasitaemia. Implementation guidance is provided in Intermittent preventive treatment for infants using sulfadoxine-pyrimethamine (IPTi-SP) for malaria control in Africa: Implementation eld guide, released in 2011 (30). Seasonal malaria chemoprevention (SMC) SMC is the intermittent administration of full treatment courses of an eective antimalarial medicine during the malaria season to prevent malarial illness in children aged between 3 and 59 months (31). WHO recommends the use of SMC in areas of highly seasonal malaria transmission5 across Africas Sahel subregion where amodiaquine plus SP are eective. SMC requires administration of a complete treatment course of amodiaquine plus SP at monthly intervals, with the rst course given at the beginning of the transmission season. A maximum of four courses can be administered during the transmission season. Implementation guidance is provided in Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine in children: A eld guide, released in 2013 (6).

Second edition (32), published in March 2010 and updated in April 2011. All updates since April 2011 can be found on the WHO website. The section below summarizes all valid guidance. The third edition of the WHO treatment guidelines is scheduled for release in 2014. Prompt parasitological conrmation by light microscopy or rapid diagnostic tests (RDTs) is recommended in all patients with suspected malaria before treatment is started. Antimalarial treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible.6 Treatment based on diagnostic testing has the following advantages over presumptive treatment of all fever episodes:

improved care of parasite-positive patients because of conrmation of infection; identication of parasite-negative patients, for whom another diagnosis must be sought, and appropriate treatment administered; avoidance of the use of antimalarial medicine in parasitenegative patients, thereby reducing side-eects, drug interactions and selection pressure for drug resistance; better public trust in the ecacy of ACT when it is used only to treat conrmed malaria cases; conrmation of malaria treatment failures; improved malaria case reporting and surveillance.

2.2.4 Diagnosis and treatment of malaria

The main objectives of an antimalarial treatment policy are to:

reduce morbidity and mortality by ensuring rapid, complete cure of Plasmodium infection, thus preventing the progression of uncomplicated malaria to severe and potentially fatal disease, as well as preventing chronic infection that leads to malaria-related anaemia; curtail the transmission of malaria by reducing the human parasite reservoir; and prevent the emergence and spread of resistance to antimalarial medicines.

Uncomplicated P. falciparum malaria should be treated with an ACT. The ve ACTs currently recommended for use by WHO are: artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus meoquine, artesunate plus SP, and dihydroartemisinin plus piperaquine. The choice of the ACT should be based on the therapeutic ecacy of the combination in the country or area of intended use. Artemisinin and its derivatives should not be used as oral monotherapies for the treatment of uncomplicated malaria because poor adherence to the required 7-day course of treatment results in only partial clearance of malaria parasites, contributing to the development of artemisinin resistance.
6. Within a short time (<2 hours) of the patients presentation at the point of care.

Current WHO recommendations for malaria diagnosis and treatment are described in the Guidelines for the treatment of malaria.
5. Areas where on average more than 60% of clinical malaria cases occur within a maximum of 4 months.

Box 2.4 The T3: Test. Treat. Track Initiative

WHO urges endemic countries, donors and malaria partners to scale up diagnostic testing, treatment and surveillance for malaria. Endemic countries and stakeholders should ensure that every suspected malaria case is tested, that every conrmed case is treated with a quality-assured antimalarial medicine, and that every malaria case is tracked in a surveillance system. T3 is derived from, and builds on, the following core WHO documents: Universal access to malaria diagnostic testing: An operational manual (2011) (33) Guidelines for the treatment of malaria, Second edition (2010) (32) Disease surveillance for malaria control: An operational manual (2012) (34) Disease surveillance for malaria elimination: An operational manual 8| WORLD (2012) (35). MALARIA REPORT 2013 Accurate diagnosis will signicantly improve the quality of patient care, ensure that antimalarial medicines are used rationally and correctly, and serve as the basis for more accurate surveillance data. The scale-up of quality-assured antimalarial medicines in the public and private sectors will ensure that all patients with conrmed malaria receive prompt treatment. Improved surveillance for malaria cases and deaths will help ministries to determine which areas or population groups are most aected, and thus target resources to where they are most needed.

P. vivax malaria should be treated with chloroquine in areas where this drug is eective. An appropriate ACT (not artesunate plus SP) should be used in areas where P. vivax resistance to chloroquine has been documented. To prevent relapses, both chloroquine and ACTs should be combined with a 14-day course of primaquine for the radical cure of P. vivax malaria, subject to consideration of the risk of haemolysis in patients with G6PD deciency. Severe malaria should be treated with injectable artesunate, followed by a complete course of an eective ACT as soon as the patient can take oral medications. Where complete parenteral treatment of severe malaria is not possible (e.g. in peripheral health posts), patients should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. Options available for pre-referral treatment are: artesunate (rectal), quinine (intramuscular, IM), artesunate (IM) or artemether (IM). In 2013, WHO released the third edition of Management of severe malaria: A practical handbook, which contains detailed guidance for clinicians (2).

without a need for G6PD testing. Pregnant women and infants under 1 year of age should not be given this treatment.

2.2.5 Management of antimalarial drug resistance

Antimalarial drug resistance is a major public health problem that hinders the control of malaria. Continuous monitoring of the ecacy of and resistance to antimalarial drugs is critical, in order to inform treatment policy and ensure early detection of changing patterns of resistance. Resistance is occurring as a consequence of several factors, including poor treatment practices, inadequate patient adherence to prescribed antimalarial regimens, and the widespread availability of artemisinin-based monotherapies and substandard forms of antimalarial medicines. WHO recommends that countries routinely conduct therapeutic drug ecacy studies to allow for measurement of the clinical and parasitological ecacy of medicines, and the detection of small changes in treatment outcomes when monitored consistently over time. These studies are considered the gold standard for determining antimalarial drug ecacy, and their results are the primary data used by national programmes to revise their national malaria treatment policies for rst- and secondline drugs, and to ensure appropriate management of clinical cases. Therapeutic drug ecacy studies are also used to detect suspected artemisinin resistance, which is dened as an increase in parasite clearance time, as evidenced by 10% of cases with parasites detectable on day 3 after treatment with an ACT. To interpret and compare results within and between regions, and to follow trends over time, therapeutic ecacy monitoring must follow standardized procedures. WHO updated the protocol for assessing antimalarial drug ecacy in 2009 (37), and has made available a guideline on genotyping malaria parasites to distinguish between reinfection and recrudescence, which is necessary as part of therapeutic ecacy testing (38). WHO recommendations for the monitoring and management of antimalarial drug resistance, published in the 2009 edition of Methods for surveillance of antimalarial drug ecacy (37), are as follows: NMCPs should establish sentinel sites for the surveillance of antimalarial drug ecacy. Experience suggests that four to eight sites per country will achieve a balance between representativeness and practicality. The sentinel sites should represent all the epidemiological strata in the country, but it is essential to select a manageable number of sites to ensure proper monitoring and supervision. Ecacy of rst- and second-line medicines should be tested at least once every 24 months at all sites. For the purposes of comparability, assessments should always be conducted at the same time of year. A follow-up of 28 days is recommended as the minimum duration for medicines with elimination half-lives of less than 7 days (amodiaquine, artemisinin derivatives, atovaquoneproguanil, chloroquine, lumefantrine, quinine and SP). For medicines with longer elimination half-lives (meoquine, piperaquine), a follow-up period of 42 days is necessary. The standard protocol to test the ecacy of medicines against P. falciparum needs to be adjusted for P. vivax. Since P. vivax infecWORLD MALARIA REPORT 2013 | 9

Box 2.5 Global Strategic Plan for P. vivax Control and Elimination
In 2013, WHO began developing a Global Strategic Plan for P. vivax Control and Elimination, to bring together all policy recommendations and programmatic guidance for P. vivax in one document for NMCPs. In addition to tailored recommendations for reducing the P. vivax burden, the plan will include guidance on possible new tools and the most urgent research priorities. The P. vivax plan is being developed in consultation with malaria-endemic countries, technical experts and key stakeholders. WHO will hold a series of regional consultations in 2014, and is expected to issue the plan before the end of 2014. Key recommendations from the P. vivax plan will be integrated into the Global Technical Strategy for Malaria Control and Elimination 20162025, which will be presented to the World Health Assembly for consideration in 2015.
In settings with limited access to health facilities, diagnosis and treatment should be provided at community level through a programme of community case management of malaria. With the introduction of malaria RDTs, malaria can be distinguished from non-malaria febrile illnesses, notably pneumonia, which is a major cause of childhood mortality. The new strategy targeting the diagnosis and treatment of malaria, pneumonia and diarrhoea at community level is termed integrated community case management (iCCM) of childhood illness.7 Following a 2012 review of evidence (36) and an assessment by the MPAC, WHO recommends the following in areas where there is a threat of artemisinin resistance and in areas targeted for P. falciparum elimination, and where primaquine is not yet deployed as gametocytocide for P. falciparum: a single 0.25 mg base/kg primaquine dose given to all patients with conrmed P. falciparum malaria on the rst day of their ACT treatment,
7. To read more, visit: http://www.who.int/malaria/areas/community_case_ management/overview/en/index.html, accessed 10 September 2013

tion has a dormant liver stage and therefore has the potential to relapse, many countries recommend primaquine therapy for radical cure. Administration of primaquine concurrently or soon after administration of chloroquine may conceal resistance to chloroquine alone, resulting in underestimation of the risk of therapeutic failure or resistance to chloroquine. Therefore, in certain cases, primaquine therapy should be postponed until after the 28-day follow-up. Nonetheless, if local health policy includes mandatory administration of primaquine with chloroquine, the failure rate should be considered to be that of the combination regimen. Countries should consider changing the rst-line treatment for malaria if the total failure rate (dened as the sum of the patients presenting with early treatment failure, late clinical failure or late parasitological failure) exceeds 10%. The selection of a new antimalarial treatment for use at public health level in the context of national treatment guidelines should be based on an average cure rate of 95% as assessed in clinical trials (32).

Box 2.6 Emergency response to artemisinin resistance in the Greater Mekong subregion
On World Malaria Day 2013, WHO launched an Emergency response to artemisinin resistance in the Greater Mekong subregion (ERAR) a regional framework for action to guide an emergency scale-up of containment eorts in aected countries. The ERAR identies four priority areas where coordinated action is needed to contain artemisinin resistance and to move towards elimination of the disease: reach all at-risk groups with full coverage of malaria interventions in priority areas achieve tighter coordination and management of eld operations obtain better information for artemisinin resistance containment strengthen regional oversight and support. To coordinate the emergency response, WHO set up a new regional hub in Phnom Penh, Cambodia in 2013. WHO estimates that about US$ 400-450 million of funding is required for the 20132015 period, to fully scale up malaria control and containment activities in the aected countries. The Global Fund to Fight AIDS, Tuberculosis and Malaria has already pledged to allocate US$ 100 million to support countries over the next 3 years. In parallel with WHOs launch of the emergency response, growing political momentum in the region led to the adoption of a consensus statement on malaria control and elimination in the Asia-Pacic at a high-level summit hosted by the Government of Australia in October 2012 in Sydney. This was followed by the adoption of the Declaration of the 7th East Asia Summit on Regional Responses to Malaria Control and Addressing Resistance to Antimalarial Medicines during the same month in Cambodia. In October 2013, leaders of the East Asia Summit endorsed the establishment of an Asia-Pacic Leaders Malaria Alliance, with a leadership group chaired by the prime ministers of Australia and Viet Nam. APLMAs work will be supported through two technical taskforces: the Taskforce on Regional Financing, and the Taskforce on Improving Access to Quality Medicines and Other Technologies.
to spread to India or sub-Saharan Africa, the global consequences could be dire, because no alternative antimalarial medicine is available at present with the same level of ecacy and tolerability as ACTs. In May 2007, the World Health Assembly called on malariaendemic countries to progressively cease the provision of oral artemisinin-based monotherapies (resolution WHA60.18), and in January 2011, WHO released the Global plan for artemisinin resistance containment (GPARC) (39) outlining the necessary actions to contain and prevent resistance to artemisinins. The GPARC outlines ve areas of action for successful management of artemisinin resistance: Stop the spread of resistant parasites. In areas where there is evidence of artemisinin resistance, an immediate comprehensive response using a combination of malaria control

Reliable data on the therapeutic ecacy of antimalarial medicines is critical both for eective case management and for early detection of changing patterns of resistance that enable timely revisions to national malaria treatment policies. Although routine therapeutic ecacy studies provide an adequate indication of drug ecacy, additional research studies are needed to conrm and characterize drug resistance. In addition, the emergence and rapid spread of antimalarial drug resistance over the past decades has heightened the urgency for a well-coordinated global monitoring system of antimalarial therapeutic ecacy. Artemisinin resistance Over the past decade, most countries endemic for P. falciparum malaria have shifted their national treatment policies to ACTs, although many of these countries still do not conduct routine therapeutic ecacy studies (39). The development of parasite resistance to artemisinins the key compounds in ACTs is a major public health concern. Resistance is occurring as a consequence of several factors, including poor treatment practices, inadequate patient adherence to prescribed antimalarial regimens, and the widespread availability of oral artemisinin-based monotherapies and substandard forms of the drug. WHOs current working denition of artemisinin resistance is: an increase in parasite clearance time detected through routine surveillance as evidenced by 10% of cases with parasites detectable on day 3 after treatment with an ACT (suspected resistance); or

treatment failure after treatment detected through research trials with an oral artemisinin-based monotherapy with adequate antimalarial blood concentration, as evidenced by the persistence of parasites for 7 days, or the presence of parasites at day 3 and recrudescence within 2842 days (conrmed resistance).8

In recent years, artemisinin resistance has been detected in four countries of the Greater Mekong subregion: Cambodia, Myanmar, Thailand and Viet Nam. If artemisinin resistance were
8. This denition is prone to confounding factors (known and unknown) such as splenectomy, haemoglobin abnormalities and reduced immunity. 10 | WORLD MALARIA REPORT 2013

and elimination measures is needed to stop the survival and spread of resistant parasites. Increase monitoring and surveillance to evaluate the threat of artemisinin resistance. Regular monitoring and surveillance is essential to rapidly identify new foci of resistant parasites, and to provide information for containment and prevention activities. Endemic countries should undertake routine monitoring of antimalarial drugs at sentinel sites every 24 months in order to detect changes in their therapeutic ecacy. Improve access to diagnostics and appropriate treatment with ACTs. Programmes should ensure the following: consistent and accurate diagnostic testing of suspected malaria cases; treatment with ACTs for conrmed cases; compliance with ACT treatment; and removal from the market of oral artemisinin-based monotherapies, as well as substandard and counterfeit antimalarial medicines. Invest in research related to artemisinin resistance. Research is important to improve understanding of resistance and the ability to manage it. Motivate action and mobilize resources. Successful implementation of the GPARC will depend on motivating stakeholders at global, regional and national levels to support or conduct the recommended activities.

system, malaria surveillance systems rely on the reporting and use of aggregate data by district and higher administrative levels. Malaria surveillance is frequently integrated into a broader system of health information or communicable disease surveillance. At the health-facility level, case-based surveillance of malaria inpatient cases and deaths is undertaken with the aim of responding to cases of severe disease and attaining a target of zero malaria deaths. Cases are graphed monthly to assess the extent to which control measures are reducing the incidence of malaria. At district and national levels, cases and deaths are summarized monthly on ve control charts, in order to assess the impact of malaria control interventions and identify trends that require an urgent response. The ve areas covered by the control charts are malaria incidence and mortality rates, proportional malaria incidence and mortality rates, general patient attendance rates, diagnostic activity (annual blood examination rate), and quality of diagnosis and health-facility reporting. Analysis is also undertaken by health-facility catchment area and by district in order to set priorities for malaria control activities.

2.3.2. Malaria surveillance systems in the control phase: low-transmission settings

Registers of individual malaria cases are maintained at health facilities, with records of the diagnostic tests performed and test results obtained. As well as aggregate data being reported to district and higher administrative levels, line lists of inpatients and inpatient deaths are forwarded to district level; in addition, when case loads and district capacity permit (e.g. <150 patients per district per month), lists of all conrmed cases are submitted monthly. At health-facility level, case-based surveillance of malaria cases and deaths is undertaken, with the aim of identifying population groups with the highest malaria incidence and probable sources of infection. Cases are graphed daily or weekly to identify trends that require attention, and are mapped by village to identify clusters of cases. At the district level, malaria cases and deaths are summarized weekly or monthly on the same ve control charts used in hightransmission settings, to assess the impact of malaria control interventions and identify trends that require urgent response. Analysis is undertaken by health-facility catchment area and by village, to set priorities for activities. A register of severe cases and deaths is maintained and investigations are undertaken to identify and address programme weaknesses. At national level, cases and deaths are summarized monthly on the ve control charts, to assess the impact of malaria control interventions. Analysis is undertaken by district, to set priorities for activities.

2.3 Malaria surveillance

Strong malaria surveillance systems are fundamental to both programme design and implementation. They are needed to target resources to the populations most in need and to respond to unusual trends, such as outbreaks of cases or the absence of a decrease in the number of cases despite widespread implementation of interventions. The design of malaria surveillance systems depends on two factors: the level of malaria transmission and the resources available to conduct surveillance. In countries that are in the malaria control phase, and in areas of moderate to high transmission, case incidence rates are often so high that it is not possible to examine and react to each conrmed case individually; rather, analysis must be based on aggregate numbers, and action taken at a population level. As transmission is progressively reduced, it becomes increasingly possible, and necessary, to track and respond to individual cases. In the elimination phase, malaria programmes need to detect each infection, whether or not it is symptomatic, and investigate each case to ascertain whether the infection was imported or locally acquired, and undertake appropriate control measures. The principal features of surveillance systems in dierent stages of control are summarized below. Further details can be found in the operation manuals Disease surveillance for malaria control (34) and Disease surveillance for malaria elimination (35), which were launched by the WHO Director-General in 2012.

2.3.3. Malaria surveillance systems in the elimination phase

Case-based surveillance is carried out and each conrmed case is immediately notied to district, provincial and central levels. A full investigation of each case is undertaken to determine whether the infection was imported, acquired locally by mosquito-borne transmission (introduced, indigenous or relapsed) or induced. The national reference laboratory reconrms all positive test results and a sample of negative test results, and organizes laboratory participation in a national quality-assurance (QA) network.
WORLD MALARIA REPORT 2013 | 11

2.3.1. Malaria surveillance systems in the control phase: high and moderate transmission settings
Registers of individual cases are maintained at health facilities, and allow recording of diagnostic tests performed and test results. Given the high frequency of malaria cases and the limited resources for maintaining an extensive recording and reporting

Each new focus of transmission is investigated, including an entomological investigation, to ascertain risk factors and devise the optimal strategies for control. The focus is classied and its status is updated continuously. The malaria programme monitors the extent of surveillance, mainly by tracking blood examination rates by village and by month in high-risk foci, then comparing the number of diagnostic tests done with the number expected. Depending on the situation, other response measures (e.g. active case detection) may be initiated. Programme managers at district level keep the following:

response to new cases. This transformation phase precedes a decision to reorient programmes towards elimination.

Countries with low, unstable transmission should be encouraged to proceed to malaria elimination. Before making this decision, however, countries should take account of the overall feasibility of elimination, including the entomologic situation, programmatic capacity, political and scal commitment, and potential threats to success, including the malaria situation in neighbouring countries. Malaria elimination may also require regional initiatives, cross-border collaboration, and strong political commitment. Countries with an absence of locally acquired malaria cases for 3 consecutive years, and with suciently robust surveillance and reporting systems in place to demonstrate this achievement, are eligible to ask WHO to initiate procedures for certication that they are malaria free.

malaria case investigation forms, patient records, focus investigation forms and a register of foci with changes in status; maps showing the distribution of cases by household, vector breeding places, possible sites of transmission and geographical features, such as hills, rivers and roads; and data on integrated vector control interventions.

Full documentation of programme activities and surveillance results is kept securely at national level in preparation for certication of malaria elimination.

Failure to sustain malaria control will result in a resurgence of malaria. Therefore, public and government commitment to intensied malaria control and elimination needs to be sustained even after the malaria burden has been greatly reduced.

2.4 Malaria elimination

Box 2.7 Denitions of control, elimination, certication and eradication (40)
Malaria control: the reduction of the malaria disease burden to a level at which it is no longer a public health problem. Malaria elimination: the reduction to zero of the incidence of infection caused by human malaria parasites in a dened geographical area as a result of deliberate eorts. Continued measures to prevent re-establishment of transmission are required. Certication of malaria-free status: the ocial recognition of malaria-free status granted by WHO after it has been proven beyond reasonable doubt that the chain of local human malaria transmission by Anopheles mosquitoes has been fully interrupted in an entire country for at least 3 consecutive years. Malaria eradication: permanent reduction to zero of the worldwide incidence of infection caused by a particular malaria parasite species. Intervention measures are no longer needed once eradication has been achieved.
From a country perspective, interruption of local mosquitoborne malaria transmission (i.e. elimination of malaria) is the ultimate goal of malaria control. The WHO recommendations regarding malaria elimination are summarized below (40, 41):

2.5 Goals and targets for malaria control and elimination

Malaria control forms part of Millennium Development Goal (MDG 6) to halt by 2015 and begin to reverse the incidence of malaria and other major diseases. Given that malaria accounted for 7% of post-neonatal child deaths globally in 2010 and 15% of post-neonatal child deaths in Africa (42), it is also central to MDG 4 (to achieve a two thirds reduction in the mortality rate among children under 5 years of age between 1990 and 2015). Malaria control is additionally expected to contribute to achievement of MDG 1 (eradicate extreme poverty and hunger), MDG 2 (achieve universal primary education) MDG 3 (promote gender equality and empower women), MDG 5 (improve maternal health) and MDG 8 (develop a global partnership for development). In 2005, the World Health Assembly set as a target the reduction of malaria cases and deaths by 75% by 2015 (43). In 2011, the RBM Partnership updated the objectives, targets and milestones that had been set out in the Global Malaria Action Plan in 2008 (44). The update retained the objective of reducing malaria cases by 75% from 2000 levels by 2015, but also had a more ambitious target: the reduction of malaria deaths to near zero by 20159 (see Table 2.1). The objectives of mortality and morbidity reduction are linked to targets for malaria prevention and case management, and to the milestones for individual years before 2015. Another objective is to eliminate malaria by the end of 2015 in 810 new countries (since 2008) and in the WHO European Region.

In areas of high, stable transmission, where a marked reduction in malaria transmission has been achieved, a consolidation period should be introduced, in which achievements are sustained, even in the face of limited disease; control strategies are reviewed; health services adapt to the new clinical and epidemiological situation, including reduced levels of immunity; and surveillance systems are strengthened to allow rapid

2.6 Indicators of progress

The updated objectives, targets and milestones provide direction for the implementation of NMCPs; they also provide a
9. Near zero malaria deaths is dened as no more than 1 conrmed malaria death per 100 000 population at risk, in areas where public health facilities are able to provide a parasitological test to all suspected malaria cases.

12 | WORLD MALARIA REPORT 2013

framework for monitoring and evaluation. A list of recommended indicators against each target is shown in Table 2.2. The selection of indicators is the same as those outlined previously in the World malaria report 2012 (45), except for indicators used to monitor the uptake of IPTp, which have been revised in light of the updated IPTp recommendation. WHO now recommends IPTp with SP for all pregnant women at each scheduled antenatal care visit after the rst trimester, in areas of moderate to high malaria transmission in sub-Saharan Africa. The rst IPTp-SP dose should be administered as early as possible during the second trimester of pregnancy. (See section 2.2.3) Considering that WHO recommends four scheduled ANC visits, and the rst visit may occur in the rst trimester, IPTp indica-

tors now emphasize the proportion of pregnant women who receive three or more doses of IPTp-SP during their pregnancy. Supportive indicators include the proportion of pregnant women who receive one, two, three and four doses in relation to the number of ANC visits made. Indicators that can be generated from household surveys are shown in bold. In some cases, the indicators generated by household surveys (e.g. parasite prevalence) do not measure a target directly, but the indicator is in widespread use and is therefore placed by the most appropriate RBM target.

Table 2.1 Updated Global Malaria Action Plan (GMAP) objectives, targets, and milestones beyond 2011
Objective Targets Milestones

Objective 1 Reduce global malaria deaths to near zero by end 2015

Target 1.1 Achieve universal access to case management in the public sector. By end 2013, 100% of suspected malaria cases receive a malaria diagnostic test and 100% of conrmed cases receive treatment with appropriate and eective antimalarial drugs. Target 1.2 Achieve universal access to case management, or appropriate referral, in the private sector. By end 2015, 100% of suspected malaria cases receive a malaria diagnostic test and 100% of conrmed cases receive treatment with appropriate and eective antimalarial drugs. Target 1.3 Achieve universal access to community case management (CCM) of malaria. By end 2015, in countries where CCM of malaria is an appropriate strategy, 100% of fever (suspected) cases receive a malaria diagnostic test and 100% of conrmed uncomplicated cases receive treatment with appropriate and eective antimalarial drugs, and 100% of suspected and conrmed severe cases receive appropriate referral.

None, as the target is set for 2013.

By end 2013, in endemic countries, 50% of persons seeking treatment for malaria-like symptoms in the private sector report having received a malaria diagnostic test and 100% of conrmed cases having received treatment with appropriate and eective antimalarial drugs. 1. By end 2012, all countries where CCM of malaria is an appropriate strategy have adopted policies to support CCM of malaria (including use of diagnostic testing and eective treatment). 2. By end 2013, in all countries where CCM of malaria is an appropriate strategy, 80% of fever cases receive a malaria diagnostic test and 80% of conrmed cases receive treatment with eective antimalarial drugs. None, as the target is set for 2013.

Objective 2 Reduce global malaria cases by 75% by end 2015 (from 2000 levels)

Target 2.1 Achieve universal access to and utilization of prevention measures. By end 2013, in countries where universal access and utilization have not yet been achieved, achieve 100% access to and utilization of prevention measures for all populations at risk with locally appropriate interventions. Target 2.2 Sustain universal access to and utilization of prevention measures. By 2015 and beyond, all countries sustain universal access to and utilization of an appropriate package of preventive interventions. Target 2.3 Accelerate development of surveillance systems. By end 2015, all districts are capable of reporting monthly numbers of suspected malaria cases, number of cases receiving a diagnostic test and number of conrmed malaria cases from all public health facilities, or a consistent sample of them.

From 2013 through 2015, universal access to and utilization of appropriate preventive interventions are maintained in all countries.

By end 2013, 50% of malaria endemic countries have met the 2015 target.

Objective 3 Eliminate malaria by end 2015 in 10 new countries (since 2008) and in the WHO European Region

By end 2013, malaria is eliminated in 3 new countries.

WORLD MALARIA REPORT 2013 | 13

Table 2.2 Indicators for measuring progress towards GMAP objectives and targets
GMAP Objective or Target
k Objective 1 Reduce global malaria deaths to near zero* by end 2015 k Target 1.1 Achieve universal access to case management in the public sector Target 1.2 Achieve universal access to case management, or appropriate referral, in the private sector Target 1.3 Achieve universal access to community case management (CCM) of malaria k k

Key Indicator
Inpatient malaria deaths per 1000 persons per year All-cause under 5 mortality rate Proportion of suspected malaria cases that receive a parasitological test Proportion of children under 5 years old with fever in the last 2 weeks who k had a nger or heel stick Proportion of conrmed malaria cases that receive rst-line antimalarial treatment according to national policy Proportion receiving rst-line treatment among children under 5 years old with fever in the last 2 weeks who received any antimalarial drugs k k k k

Further Analysis
Has health facility reporting completeness changed over time? What factors are responsible? k k

Supporting Indicator
Completeness of monthly health facility reports Programme coverage indicators in this table (detailed below)

Are people seeking advice or treatment for fever and from where? Are adequate quantities of antimalarial medicines available?

Proportion of children under 5 years old with fever in the last 2 weeks for whom advice or treatment was sought Proportion of health facilities without stock-outs of key commodities by month

Objective 2 Reduce global malaria cases by 75% by end 2015 (from 2000 levels)

Conrmed malaria cases (microscopy or RDT) per 1000 persons per year

k k

Has diagnostic eort changed over time? Has health facility reporting completeness changed over time? Have test positivity rates changed over time? Is there other evidence of morbidity change? How many households have at least one ITN? How many households have enough ITNs for each occupant? Were enough ITNs delivered to ensure at least one ITN per two people at risk? Are specic risk groups receiving ITNs? Are specic population groups using ITNs?

k k k k k k k k k k k

Annual blood examination rate Completeness of monthly health facility reports Malaria test positivity rate Proportion of children aged 659 months with a hemoglobin measurement of <8g/dL Proportion of households with at least one ITN Proportion of households with at least one ITN for every two people Proportion of population at risk potentially covered by ITNs distributed Proportion of targeted risk group receiving ITNs Proportion of children under 5years old who slept under an ITN the previous night Proportion of pregnant women who slept under an ITN the previous night Proportion of existing ITNs used the previous night

Parasite prevalence: proportion of children aged 659 months with malaria infection

k k

Proportion of population with access to an ITN within their household

k k k

Target 2.1 Achieve universal access to and utilization of prevention measures** Target 2.2 Sustain universal access to and utilization of prevention measures**

Proportion of population that slept under an ITN the previous night

k k k Proportion of population protected by IRS within the last 12 months Proportion of households with at least one ITN for every two people and/or sprayed by IRS within the last 12 months Proportion of women who received at least three or more doses of IPTp during ANC visits during their last pregnancy Percent of districts reporting monthly numbers of suspected malaria cases, number of cases receiving a diagnostic test and number of conrmed malaria cases Number of new countries in which malaria has been eliminated k k

Are available ITNs being used?

How many households have been reached with at least one vector control method?

Proportion of households with at least one ITN and/or sprayed by IRS within the last 12 months Proportion of women who received at least one, two or four doses of IPTp during ANC visits during their last pregnancy Proportion of women attending ANC who received at least one, two, three or four doses of IPTp

Is IPTp received by all pregnant women at each scheduled ANC visit?

Target 2.3 Accelerate development of surveillance systems Objective 3 Eliminate malaria by end 2015 in 10 new countries (since 2008) and in the WHO European Region

What are the trends in malaria cases? How strong are surveillance systems?

k k k

Number of active foci reported per year Number of cases by classication (indigenous, introduced, imported, induced) Proportion of private facilities reporting to national malaria surveillance system

Indicators derived from household surveys are in bold. * In areas where public health facilities are able to provide a parasitological test for all suspected malaria cases, near zero malaria deaths is dened as no more than 1 conrmed malaria death per 100,000 population at risk. ** Universal access to and utilization is dened as every person at risk sleeping under a quality insecticide-treated net or in a space protected by indoor residual spraying and every pregnant woman at risk receiving a dose of IPTp at each ANC visit after the rst trimester (in settings where IPTp is appropriate). 14 | WORLD MALARIA REPORT 2013

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16. Insecticide-treated mosquito nets: A WHO position statement. Geneva, World Health Organization (WHO), 2007 (http://www. who.int/malaria/publications/atoz/itnspospaperfinal.pdf, accessed 15 October 2013). 17. WHO recommended long-lasting insecticidal nets (updated May 2013). Geneva, World Health Organization Pesticide Evaluation Scheme (WHOPES), 2013 (http://www.who.int/whopes/Long_ lasting_insecticidal_nets_May_2013.pdf, accessed 15 October 2013). 18. Guidelines for procuring public health pesticides. Geneva, World Health Organization, 2012 (http://whqlibdoc.who.int/publications/2012/9789241503426_eng.pdf, accessed 15 October 2013). 19. Guidelines for monitoring the durability of long-lasting insecticidal mosquito nets under operational conditions. Geneva, World Health Organization, 2011 (http://whqlibdoc.who.int/publications/2011/9789241501705_eng.pdf, accessed 15 October 2013). 20. A proposal to improve value for money in LLIN procurement through market competition based on cost per year of eective coverage. Concept note, Geneva, World Health Organization, 2011 (http:// www.who.int/malaria/publications/atoz/gmpllin_effective_ coverage_concept_note.pdf, accessed 15 October 2013). 21. WHO recommended insecticides for indoor residual spraying against malaria vectors (updated October 2009). Geneva, World Health Organization (WHO), 2009 (http://www.who.int/whopes/ Insecticides_IRS_Malaria_09.pdf, accessed 15 October 2013). 22. The use of DDT in malaria vector control. WHO position statement. Geneva, World Health Organization (WHO), 2011 (http://www. who.int/malaria/publications/atoz/who_htm_gmp_2011/en/ index.html, accessed 15 October 2013). 23. Decision adopted by the Conference of the Parties to the Stockholm Convention at its sixth meeting. SC-6/1: DDT, May 2013 (http:// www.who.int/malaria/publications/atoz/stockolm_convention_ decision_COP6_on_DDT_june13.pdf, accessed 10 November 2013). 24. WHOPES-recommended compounds and formulations for control of mosquito larvae (updated September 2012). Geneva, World Health Organization Pesticide Evaluation Scheme (WHOPES), 2009 (http://www.who.int/whopes/Mosquito_Larvicides_Sept_2012. pdf, accessed 15 October 2013). 25. WHO interim position statement the role of larviciding for malaria control in sub-Saharan Africa. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/atoz/larviciding_ position_statement/en/index.html, accessed 15 October 2013). 26. Global plan for insecticide resistance management in malaria vectors. Geneva, World Health Organization, 2012 (http://www.who.int/ malaria/publications/atoz/gpirm/en/index.html, accessed 15 October 2013). 27. WHO Evidence Review Group. Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). Meeting report, 911 July 2012, Geneva, World Health Organization (WHO), 2012 (http://www.who.int/malaria/mpac/ sep2012/iptp_sp_erg_meeting_report_july2012.pdf, accessed 15 October 2013). 28. WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTpSP). Geneva, World Health Organization (WHO), 2013 (http://www. who.int/malaria/publications/atoz/policy_brief_iptp_sp_policy_ recommendation/en/index.html, accessed 15 October 2013). 29. WHO policy recommendation on intermittent preventive treatment during infancy with sulphadoxine-pyrimethamine (SP-IPTi) for Plasmodium falciparum malaria control in Africa. Geneva, World Health Organization (WHO), 2010 (http://www.who.int/malaria/ news/WHO_policy_recommendation_IPTi_032010.pdf, accessed 15 October 2013). WORLD MALARIA REPORT 2013 | 15

30. Intermittent preventive treatment for infants using sulfadoxine-pyrimethamine (SP-IPTi) for malaria control in Africa: Implementation eld guide. Geneva, World Health Organization (WHO) Global Malaria Programme (GMP) and Department of Immunization, Vaccines and Biologicals (IVB) and United Nations Childrens Fund (UNICEF), 2011 (http://whqlibdoc.who.int/hq/2011/WHO_ IVB_11.07_eng.pdf, accessed 15 October 2013). 31. WHO policy recommendation: Seasonal malaria chemoprevention (SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa. Geneva, World Health Organization (WHO), 2013 (http://www.who.int/malaria/ publications/atoz/who_smc_policy_recommendation/en/index. html, accessed 15 October 2013). 32. Guidelines for the treatment of malaria, Second edition. Geneva, World Health Organization, 2010 (http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf, accessed 15 October 2013). 33. Universal access to malaria diagnostic testing An operational manual. 2011, (http://www.who.int/malaria/publications/ atoz/9789241502092/en/index.html, accessed 22 October 2013). 34. Disease surveillance for malaria control: An operational manual. Geneva, World Health Organization, 2012 (http://www.who. int/malaria/publications/atoz/9789241503341/en/index.html, accessed 15 October 2013). 35. Disease surveillance for malaria elimination: An operational manual. Geneva, World Health Organization, 2012 (http://www.who. int/malaria/publications/atoz/9789241503334/en/index.html, accessed 15 October 2013). 36. WHO Evidence Review Group. The safety and eectiveness of single dose primaquine as a P. falciparum gametocytocide. Meeting report, 1315 August 2012, Bangkok, World Health Organization (WHO), 2012 (http://www.who.int/malaria/mpac/sep2012/primaquine_ single_dose_pf_erg_meeting_report_aug2012.pdf, accessed 15 October 2013). 37. Methods for surveillance of antimalarial drug ecacy. Geneva, World Health Organization, 2009 (http://whqlibdoc.who.int/publications/2009/9789241597531_eng.pdf, accessed 15 October 2013). 38. Methods and techniques for clinical trials on antimalarial drug ecacy: genotyping to identify parasite populations. Informal consultation organized by the Medicines for Malaria Venture and cosponsored by WHO, Geneva, World Health Organization (WHO), 2008 (http:// whqlibdoc.who.int/publications/2008/9789241596305_eng.pdf, accessed 15 October 2013). 39. Global plan for artemisinin resistance containment. Geneva, World Health Organization, 2011 (http://www.who.int/malaria/publications/atoz/9789241500838/en/, accessed 15 October 2013). 40. Global malaria control and elimination: Report of a technical review. Geneva, World Health Organization, 2008 (http://www.who. int/malaria/publications/atoz/9789241596756/en/index.html, accessed 15 October 2013). 41. Mendis K, Rietveld A, Warsame M, Bosman A, Greenwood B, Wernsdorfer WH. From malaria control to eradication: The WHO perspective. Med Int Health, 2009, 14(7):802809 (http://www. ncbi.nlm.nih.gov/pubmed/19497083, accessed 20 October 2013). 42. Liu L. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet, 2012, 9832:21512161 (http://www.ncbi.nlm.nih.gov/ pubmed/22579125, accessed 19 October 2013). 43. Resolution WHA58.2. Malaria control. Fifty-eighth World Health Assembly (WHA)1625 May, Geneva, World Health Organization, 2005 (http://www.who.int/malaria/publications/WHO_malaria_ resolution_2005.pdf, accessed 15 October 2013). 44. Rened/updated GMAP objectives, targets, milestones and priorities beyond 2011 Geneva, Roll Back Malaria Partnership, 2011 (http://

whqlibdoc.who.int/publications/2011/9789241502061_eng.pdf, accessed 15 October 2013). 45. World Malaria Report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/world_malaria_ report_2012/en/index.html, accessed 15 October 2013).

16 | WORLD MALARIA REPORT 2013

CHAPTER 3

Financing malaria control

This chapter reviews (i) recent trends in international and domestic nancing for malaria control in relation to resource requirements; (ii) the distribution of funds by WHO region, disease burden and national income; and (iii) the willingness of endemic countries to pay for malaria control. disbursed funds in 2011 and 50% in 2013. In 2011, the Global Fund announced the cancellation of Round 11 of grant awards. A transitional-funding mechanism was established to ensure continuity of programmes in countries due for grant renewal in Round 11; however, this mechanism did not allow for further scale-up of programmes, and it covered only the continuation of previously funded services. In 2012, the Global Fund launched an interim new funding modality that included US$ 519 million for malaria, with a particular focus on replacement of long-lasting insecticidal nets (LLINs). In 2012, the Global Fund Board approved a new funding model that will be launched in 2013, and will provide funding for the years 20142016. To make nancing more predictable, countries will be assigned an indicative amount of funding according to their malaria burden and ability to pay for malaria control. At a global level, it is expected that malaria programmes will, in aggregate, be allocated 32% of the total amount of funds disbursed by the Global Fund initially. However, the nal amounts allocated for malaria control may vary from this proportion, and they are subject to change according to priorities set by a country. Thus, proportions allo-

3.1 International nancing of malaria control

International disbursements to malaria-endemic countries increased from less than US$ 100 million in 2000 to US$ 1.60 billion in 2011; they were estimated to be US$ 1.94 billion in 2012 and US$ 1.97 billion in 2013 (Figure 3.1, Box 3.1). Increases in international funding have slowed in recent years, falling to an average of 4% per year between 2009 and 2013, compared to average increase of 43% per year between 2005 and 2009. A lower level of funding in 2011 was mainly due to lower levels of disbursements from the Global Fund. The Global Fund is the largest source of funding for malaria control globally; it accounted for 40% of the estimated total

Box 3.1 Sources of information on international and domestic funding for malaria control
The Global Fund supplied information on disbursements for malaria control to WHO up to October 2013. Disbursements for 2013 were annualized by multiplying by 1.2 (i.e. 12/10). At the time of publication of this report, the results of the Global Fund Fourth Replenishment were unknown. It is assumed that, of the US$ 12 billion pledged by donors at the Fourth Replenishment, 32% will be allocated to malaria and that funds will be dispersed evenly over 20142016. Information on funding from PMI is based on the commitments in the PMIs operational plans (1, 2). For the calendar year 2012, PMI funding is recorded as US$ 555 million, and is assumed to remain at that level until 2015. For other development agencies, information on disbursements is available up to and including 2011, through the Organisation for Economic Co-operation and Development (OECD) Development Co-operation Directorate database on ocial development assistance (3). DFID funding to endemic countries for malaria control, excluding the funds it provides to the Aordable Medicines Facility malaria (AMFm), is projected to increase from US$ 103 million in 2011 to US$ 226 million in 2015, in line with previous funding trends. Funding from the PMI and DFID are subject to annual legislative review. For the World Bank, future funding is assumed to remain at 2011 levels the latest year for which data are available at US$ 82 million. This assumption is also made for agencies falling into the other category of Figure 3.1. AMFm disbursements between 2010 and 2013 totalled US$ 384 million. Support for private sector case management has now been rolled into general Global Fund grant applications; hence, it is not shown separately beyond 2013 (4). Projected disbursements from the Australian Agency for International Development (AusAID) now absorbed into the Australian Government Department of Foreign Aairs and Trade (DFAT) include US$ 100 million pledged in November 2012 over the course of 4 years, starting in 2013 (5). WHO obtains information on domestic nancing from data submitted by national malaria control programmes (NMCPs) for the World malaria report. Such reports include malaria-specic expenditures incurred by NMCPs for commodities, programme supervision and management, training, and behavioural change interventions. However, they exclude general health systems spending such as the cost of health workers, hospitals, clinics and other infrastructure for the treatment of malaria, which are typically provided by the national governments or supported by nongovernmental organizations (NGOs). Where data from NMCP were unavailable for a specic year, data from neighbouring years were used to impute a value (in cases where this was not possible, information on domestic spending contained in Global Fund grant applications was used) (6).

WORLD MALARIA REPORT 2013 | 17

Figure 3.1 Past and projected international funding for malaria control, 2000-2016
Global Fund 2 500 2 000 US$ (millions) 1 500 1 000 500 0 PMI/USAID DFID World Bank AMFm CIDA AusAID Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

AMFm, Aordable Medicines Facility malaria; AusAID, Australian Agency for International Development; CIDA, Canadian International Development Agency; DFID, Department for International Development; GF, Global Fund; PMI, Presidents Malaria Initiative; USAID, United States Agency for International Development; WB, World Bank For the GF and PMI/USAID, funds from the last quarter of 2013 onwards are projected; for other agencies, funds from 2012 onwards are projected. Source: See Box 3.1

cated to malaria control may be reduced if countries do not articulate a strong case for investment in malaria control. Funding from the United States (US) Presidents Malaria Initiative (PMI)/US Agency for International Development (USAID) showed increases year on year between 2004 and 2011, but levelled o in 2012, when PMI/USAID funding accounted for 29% of international funding. Disbursements from the United Kingdom of Great Britain and Northern Irelands Department for International Development (DFID) increased by more than threefold between 2008 and 2011, when it accounted for 7% of global international funding. The Canadian Government also markedly increased its spending on malaria control from 2008 onwards, through the Canadian International Development Agency (CIDA), which is now incorporated into Foreign Aairs, Trade and Development Canada. Estimates of the funds available for malaria control between 2012 and 2015 are projected from formal commitments made by funding agencies or, if data are not available, from previous trends in nancing (Box 3.1). If the funding assumptions given in Box 3.1 are accurate, then international funds available for malaria control can be expected to increase to US$ 2.3 billion per year between 2014 and 2016. However, to avoid disruptions in malaria control programmes and resurgences in disease, the Global Funds new funding model needs to become fully operational early in 2014, and countries need to be able to access funds promptly.
Figure 3.2 Domestic funding for malaria control, 2005-2012
AFR 700 600 500 400 US$ (millions) 300 200 100 0 2005 2006 2007 2008 2009 2010 2011 2012 AMR EMR EUR SEAR WPR

3.2 Domestic nancing of malaria control

Reported data suggest that global domestic nancing for malaria increased over the period 20052012, from US$ 436 million in 2005 to US$ 522 million in 2012 (Figure 3.2). A decrease between 2011 and 2012 was mainly due to lower reported expenditures
Figure 3.3 Domestic and external disbursements by WHO region, 2005-2012
2012 2011 2010 2009 2008 2007 2006 2005 Domestic AFR International Domestic AMR International Domestic EMR International Domestic EUR International Domestic SEAR International Domestic WPR International 0 200 400 600 800 US$ Millions
Source: See Box 3.1.

1000

1200

1400

1600

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

18 | WORLD MALARIA REPORT 2013

in India down from $US 99 million in 2011 to $US 47 million in 2012 which appears to be due to dierences in the way in which data are reported rather than necessarily a real decrease in malaria funding. If India is excluded from global totals, then domestic government malaria spending rose at a rate of 3% per year between 2005 and 2012. However, the increase in absolute totals does not consider population growth and ination, which generally exceeds 3% for malaria endemic countries.

tional resources indicate that total funding for malaria control will reach about $US 2.85 billion between 2014 and 2016.

3.4 Distribution of available funding by WHO region

Figure 3.3 shows domestic and external disbursements in 20052012 according to WHO region. Funding trends are dominated by the large increases in international disbursements to the African Region between 2005 and 2012, with that region accounting for 38% of total malaria funding in 2005, and 62% in 2012. However, the African Region experienced successive decreases in international funding in 2010 and 2011. Funding levels recovered in 2012, although the eects of this increase on programme implementation may not be realized until 2013. Although total funding for malaria control is highest in the African Region (Figure 3.3), the highest rates of funding per person at risk are seen in the European Region (Figure 3.4). Funding in this region has decreased in recent years from more than US$ 40 million per year in 2008 and 2009, to US$

3.3 Comparison of resources available and resource requirements

Global resource requirements for malaria control were estimated in the 2008 Roll Back Malaria (RBM) Global Malaria Action Plan (GMAP) to exceed US$ 5.1 billion per year between 2011 and 2020. In Africa alone, the resource requirements estimated by GMAP were, on average, US$ 2.3 billion per year during the same period (7). Combining both domestic and international funds, the resources available for malaria control globally were estimated to be US$ 2.5 billion in 2012, leaving a gap of US$ 2.6 billion. Available projections of both domestic and interna-

Figure 3.4 Malaria nancing per person at risk, by WHO region and funding source, 20052012
Government 3.0 2.5 US$ per person at risk 2.0 1.5 1.0 0.5 0 1.5 2005 2006 2007 2008 EMR US$ per person at risk 2009 2010 2011 2012 US$ per person at risk AFR Global Fund 3.0 2.5 2.0 1.5 1.0 0.5 0 40 30 20 10 0 2005 2006 2007 2008 EUR 2009 2010 2011 2012 PMI DFID World Bank AMR CIDA AusAID Other

US$ per person at risk

1.0

0.5

2005

2006

2007

2008

2009

2010

2011

2012

2005

2006

2007

2008

2009

2010

2011

2012

0.5 0.4 US$ per person at risk 0.3 0.2 0.1 0

SEAR US$ per person at risk

0.5 0.4 0.3 0.2 0.1 0

WPR

2005

2006

2007

2008

2009

2010

2011

2012

2005

2006

2007

2008

2009

2010

2011

2012

AFR, African Region; AMR, Region of the Americas; AusAID, Australian Agency for International Development; CIDA, Canadian International Development Agency; DFID, Department for International Development; EMR, Eastern Mediterranean Region; EUR, European Region; GF, Global Fund; PMI, Presidents Malaria Initiative; SEAR, South-East Asia Region; WB, World Bank; WPR, Western Pacic Region Source: See Box 3.1

WORLD MALARIA REPORT 2013 | 19

Figure 3.5 Domestic and international disbursements per person at risk for malaria, 20072011, according to: (a) GNI per capita, and (b) estimated malaria mortality rates, 2000
Government Disbursements for malaria control per person at risk capita per year 20072011 (US$) 5 4 3 2 1 0 Global Fund 8 Disbursements for malaria control per person at risk capita per year 20072011 (US$) 7 6 5 4 3 2 1 0 Highest mortality Fourth Middle Second Lowest mortality PMI DFID World Bank CIDA AusAID Other

Poorest

Fourth

Middle

Second

Richest

Countries ranked by GNI per capita 2012

Countries ranked by malaria mortality rates 2000

AusAID, Australian Agency for International Development; CIDA, Canadian International Development Agency; DFID, Department for International Development; GF, Global Fund; GNI, gross national income; PMI, Presidents Malaria Initiative; WB, World Bank Data on international disbursements by country are available only up to 2011 for most agencies (See Box 3.1) Source: See Box 3.1 GNI per capita: World Development Indicators 2013, (http://wdi.worldbank.org/tables) Malaria mortality rates: WHO calculations.

22 million in 2012 mainly because of reductions in spending in Turkey, although Turkeys spending remains the highest per person at risk for malaria in the world. The lowest rates of spending per person at risk are seen in the South-East Asia Region and the Western Pacic Region, potentially because these regions contain countries with large populations at risk that may be over-estimated. In particular, if populations at risk are dened at a comparatively high administrative level (e.g. at the province level), all of the population may be classied as being at high risk, even if the risk is actually conned to a limited part of the administrative area. Funding sources vary among WHO regions. In the European Region and the Region of the Americas most malaria funding (88%) in 2012 was from domestic governments. In other regions, domestic funding represents a less signicant source of funds (ranging from 10% of total funds available for malaria control in the African Region to 52% in the Western Pacic Region). In the African Region PMI and other donors contribute signicant shares of malaria funding in addition to the Global Fund, whereas in other WHO regions the Global Fund is the principal source of international nancing.

The high expenditures are partly related to the drive towards elimination of malaria in some countries. International assistance is focused on countries that are in the lowest two quintiles of GNI per capita and that generally have the highest malaria mortality rates. Countries in the middle-income quintiles appear to have fewer resources for malaria control because domestic investments in malaria control are low and these countries are receiving little international assistance.

3.6 Endemic countrys willingness to pay for malaria control

International assistance is critical if reductions in malaria cases and deaths are to be achieved. Nonetheless, domestic governments of malaria endemic countries have a signicant role to play in nancing malaria control. Domestic government expenditure on malaria might be expected to increase in line with the total government budget or the total revenue available. In other words, bigger or richer countries are likely to spend more. The expenditure on malaria might also be expected to be more in populous countries where the disease burden is higher. More specically, the level of government spending should reect the amount of resources required to provide preventive interventions to populations at risk, diagnostic testing and treatment to those who have malaria, and the management systems necessary to run a malaria control programme. These two assumptions imply that malaria expenditure should rise with the total government budget, and with the resource need or, in practice, with the product of the two. Indeed, the product of resource availability and resource need appears to be largely correlated with actual government expenditures (Figure 3.6). By comparing this product with actual government expenditure, it is possible to construct an index of a countrys willingness to pay for malaria control; that is, it is possible to construct a domestic investment priority index (DIPI) (8). The DIPI scales the level of domestic spending, to reect the available revenue in the government budget and for the degree of burden repre-

3.5 Distribution of available funding by disease burden and national income

Figure 3.5 shows domestic and external disbursements in 2005 2012 according to: (i) gross national income (GNI) per capita, and (ii) estimated malaria mortality rates. Countries in the highest quintile of GNI per capita invest a great deal more of their own money per capita on malaria control than countries in other quintiles. These wealthier countries have lower malaria burdens (accounting for just 0.6% of estimated cases in 2012 and 0.3% of deaths), and they include seven countries that spend more than US$ 5.00 per capita per year on malaria programmes (Argentina, Azerbaijan, Costa Rica, Malaysia, Mexico, Suriname and Turkey).
20 | WORLD MALARIA REPORT 2013

Figure 3.6 Government malaria expenditures 2012 in comparison with the product of resource availability and resource need Resource availability is assumed to be proportional to total domestic government expenditures. Resource need is assumed to be proportional to the cost of providing all persons at risk with protection with an ITN or IRS and providing patients with suspected malaria attending public health facilities with a diagnostic test and appropriate treatment.
Domestic government malaria expenditure (US$) 100 000 000 10 000 000 1 000 000 100 000 10 000 1 100 10 000 Domestic resource availability x Resource need (US$2 00's)
Source: Malaria nancing: national malaria control programmes Total domestic government expenditures: International Monetary Fund World Economic Outlook Database, September 2013, (http://www.imf.org/external/pubs/ft/weo/2013/02/weodata/index.aspx) Resource needs: WHO calculations based on estimated populations at risk, estimates of number of malaria cases and treatment seeking behaviour.

1 000 000

100 000 000

Figure 3.7 Malaria programme progress by DIPI within WHO regions, 2012 Resource availability is assumed to be proportional to total domestic government expenditures. Resource need is assumed to be proportional to the cost of providing all persons at risk with protection with an ITN or IRS and providing patients with suspected malaria attending public health facilities with a diagnostic test and appropriate treatment.
Elimination or pre-elimination phase Control phase: >75% reduction Control phase: 75% reduction 1 000 000

sented by malaria. Countries with a low value for the DIPI index might be thought of as showing a low priority for malaria control, whereas countries with a high value are demonstrating a high priority. Figure 3.7 shows the DIPI by WHO region, rst by phase of programme and then for those countries in the control phase by whether or not the countries achieved a >75% reduction in malaria case incidence rates between 2000 and 2012 (see Chapter 8; Section 8.1). In general, countries in the pre-elimination or elimination phase show higher values of the DIPI (median 7400, interquartile range [IQR] 240041 000). Countries that are on track to achieve a 75% decrease in malaria case incidence by 2015 have also given higher priority to domestic investment in malaria control (median 1800, IQR 6805600) than other countries in the control phase (median 470, IQR 2601400). In the African Region, this partly reects a lack of data on disease trends (see Chapter 7; Section 7.2); governments that show a greater investment priority for malaria also tend to have stronger data systems.

10 000

Domestic investment priority index

10 000

1 000

3.7 Conclusions
100

10

1 AFR AMR EMR EUR SEAR WPR

Source: Malaria nancing: national malaria control programmes Total domestic government expenditures: International Monetary Fund World Economic Outlook Database, September 2013 (http://www.imf.org/external/pubs/ft/weo/2013/02/weodata/index.aspx) Resource needs: WHO calculations based on estimated populations at risk, estimates of number of malaria cases and treatment seeking behaviour.

International disbursements to malaria-endemic countries have increased markedly, from less than US$ 100 million in 2000 to US$ 1.60 billion in 2011, and an estimated US$ 1.94 billion in 2012. Increases in international funding have slowed in recent years, to an average 4% per year between 2009 and 2013, compared to average of 43% per year between 2005 and 2009. Domestic nancing for malaria was estimated to be US$ 522 million in 2012. Combining both domestic and international funds, the resources available for malaria control globally were US$ 2.5 billion in 2012. Global resource requirements for malaria control were estimated to exceed US$ 5.1 billion per year between 2011 and 2020 in the GMAP of 2008, leaving an annual funding gap of US$ 2.6 billion. Projections of available domestic and international resources indicate that total funding for malaria control will reach about
WORLD MALARIA REPORT 2013 | 21

US$ 2.85 billion between 2014 and 2016, which is still substantially below the amount required to achieve universal access to malaria interventions. The Global Fund will implement a new funding model for the years 20142016. Countries will be assigned an indicative amount of funds according to their malaria burden and ability to pay for malaria control. At a global level, it is expected that malaria programmes will be allocated approximately 32% of the total amount of funds disbursed by the Global Fund. The amounts allocated for malaria control at country level may vary from this proportion, and they are subject to change according to priorities set by a country. To secure appropriate levels of nancing, countries will need to present a strong case for investment in malaria control. International investments in malaria control are targeted to countries with higher mortality rates and lower national incomes, particularly those in Africa. Domestic government investments are highest in wealthier countries and lowest in countries with the highest malaria mortality rates; the low rates of domestic spending seen in countries with higher disease burdens is mainly because these countries have lower national incomes per capita. Nonetheless, domestic governments with similar levels of resource availability vary in the priority they give to malaria control. Countries that display greater commitment, as measured by a domestic investment priority index (DIPI), have shown greater success in reducing malaria case incidence between 2000 and 2012 than countries with a lower DIPI.

References
1. PMI. Malaria operational plans for scal year 2011. Africa, Presidents Malaria Initiative (PMI), 2012 (http://www.pmi.gov/countries/ mops/fy11/index.html, accessed 22 November 2013). 2. PMI. Malaria operational plans for scal year 2012. Africa, Presidents Malaria Initiative (PMI), 2013 (http://www.pmi.gov/countries/ mops/fy12/index.html, accessed 22 November 2013). 3. OECD. Aid statistics. Organisation for Economic Co-operation and Development (OECD), 2013 (http://www.oecd.org/dac/stats/, accessed 22 November 2013). 4. SIIC. Report to the Board (GF/B28/04). Strategy, Investment and Impact Committee (SIIC). 5. Carr B. Australian leadership to ght malaria and save lives. Media release, 2012 (http://foreignminister.gov.au/releases/2012/bc_ mr_121102.html, accessed 22 November 2013). 6. Pigott DM, Atun R, Moyes CL, Hay SI, Gething PW. Funding for malaria control 20062010: A comprehensive global assessment. Malaria Journal, 2012, (http://www.malariajournal.com/content/11/1/246, accessed 22 November 2013). 7. RBM Partnership. The global malaria action plan. Geneva, Roll Back Malaria (RBM) Partnership, World Health Organisation, 2008 (http://www.rollbackmalaria.org/gmap/index.html, accessed 22 November 2013). 8. UNAIDS. Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS), 2010 (http://www. unaids.org/documents/20101123_globalreport_em.pdf, accessed 22 November 2013).

22 | WORLD MALARIA REPORT 2013

CHAPTER 4

Vector control for malaria

This chapter reviews: (i) the need for malaria-vector control; (ii) adoption of national policies for malaria vector control; (iii) progress towards the goal of universal insecticide treated net (ITN) access and use; (iv) the extent to which indoor residual spraying (IRS) is used by programmes, and (iv) monitoring and management of insecticide resistance in malaria vectors. be greater. However, increased coverage with IRS could decrease these estimated requirements for LLINs. Given the heterogeneity of malaria transmission in most malariaendemic areas outside Africa, it is challenging to estimate the population at risk of malaria and vector control needs, including ITNs. Among the 2.6 billion people at risk of malaria outside Africa, 568 million are considered by national malaria control programmes (NMCPs) to be at high risk, and may therefore benet from vector control measures. Nearly half (273 million) of the high-risk population outside Africa resides in India. However, the heterogeneity of transmission means that these numbers may be overestimates, because high malaria rates measured in one area may not be applicable to the entire administrative region. As denitions of malaria risk become more precise through improvements in entomologic monitoring and malaria surveillance, the estimated needs for vector control both inside and outside Africa may also become more precise.

4.1 Need for vector control

WHO recommends that, in areas targeted for malaria vector control, all persons at risk should be protected by ITNs or IRS vector control interventions with demonstrated impact in reducing malaria (1, 2). The choice of ITNs or IRS depends on a number of entomological, epidemiological and operational factors, including seasonality of transmission, housing density and distribution, and insecticide susceptibility of anopheline vectors. Malaria-endemic countries that report to WHO classify their populations as being at high risk (annual parasite index [API] of >1 malaria case/1000 persons), low risk (API <1 malaria case/1000 persons), or no risk for malaria. Areas of high malaria risk are considered most in need of vector control interventions. The need is most obvious for sub-Saharan Africa, where the characteristics of the predominant malaria vectors and the widespread presence of malaria risk indicate that almost all of the 800 million people at risk would benet from vector control with ITNs or IRS. To protect everyone at risk of malaria in sub-Saharan Africa, at least 150 million ITNs would be required each year (assuming that they are long-lasting insecticide treated nets [LLINs],1 that the typical LLIN lifespan is 3 years, and that 1 LLIN is distributed per 1.8 persons). If the average LLIN lifespan is actually less than 3 years, as suggested by some data (3), then true replacement needs could
1. While nearly all ITNs distributed in Africa are LLINs, this chapter refers to all treated nets as ITNs.

4.2 ITN/LLIN policy and implementation

4.2.1 Policy adoption and ITN/LLIN distribution
Adoption and implementation of policies for ITN/LLIN programmes in 2012, by WHO region, is shown in Table 4.1; adoption of policies by country is shown in Annex 2A. A total of 88 countries distribute ITNs free of charge, including 39 of 44 countries in the African Region with ongoing malaria transmission. In 83 countries, ITNs are distributed to all age groups; in 64 of those countries, the ITNs are distributed to all age groups through mass campaigns. Of 39 countries in the African Region that distibute ITNs free of charge 34 distribute them through, antenatal clinics (reecting policies directed at reducing the

Table 4.1 Adoption of policies for ITN programmes by WHO Region, 2012
Policy AFR AMR EMR EUR SEAR WPR Total

ITNs/ LLINs distributed free of charge ITNs/ LLINs sold at subsidized prices ITNs/ LLINs distributed to all age groups ITNs/ LLINs distributed through mass campaigns to all age groups ITNs/ LLINs distributed through antenatal clinics ITNs/ LLINs distributed through EPI clinics Number of countries/areas with ongoing transmission Number of countries/areas with ongoing Plasmodium falciparum transmission

39 14 34 31 34 26 44 43

16 1 17 13 3 21 18

9 9 6 3 1 9 9

4 3

10 10 8 4 1

10 2 10 6 5 1 10 9

88 16 83 64 49 29 99 88

5 0

10 9

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EPI, Expanded Programmes on Immmunizations; EUR, European Region; ITN, insecticide treated net; LLIN, long-lasting indecticidal net; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports WORLD MALARIA REPORT 2013 | 23

Figure 4.1 Number of LLINs delivered by manufacturers to countries in sub-Saharan Africa, 20042013
LLINs delivered by year 3 year total delivered LLINs 3 year total needed for universal access

Figure 4.2 Estimated trend in proportion of households with at least one ITN and population with access to an ITN in sub-Saharan Africa, 20002013.
95% condence interval Households owning at least one ITN Population with access to an ITN

500 450 400 350 Millions of LLINs 300 250 200 150 100 50 0

100% 80% 60% 40% 20% 0%

Proportion

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

ITN, insecticide-treated net

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013*

LLIN, long-lasting insecticidal net * The total number delivered for the rst three quarters of 2013 has been multiplied by 4/3 to provide an annual estimate. Source: Data from 7 WHOPES-approved manufacturers, collated by Milliner Global Associates.

Source: ITN coverage model from the Institute for Health Metrics and Evaluation, which takes into account ITNs supplied by manufacturers, ITNs delivered by National Malaria Control Programmes and household survey results (1). Includes Djibouti, Somalia, South Sudan and Sudan which are in the WHO Eastern Mediterranean Region. Proportion population with access to an ITN derived from relationship with household ownership of at least one ITN analyzed by linear regression in 48 household surveys 2001-2012, y= 0.77x

burden of malaria in pregnancy) and 26 distribute ITNs through Expanded Programme on Immunization (EPI) clinics. Information is provided to WHO on the number of LLINs delivered by the seven World Health Organization Pesticide Evaluation Scheme (WHOPES)-approved manufacturers that supply nearly all of the LLINs for public sector distribution in Africa.2 The number of nets delivered by manufacturers increased dramatically, from 6 million in 2004 to 145 million in 2010 (Figure 4.1); it then decreased in 2011 (92 million) and 2012 (70 million). However, based on information to the end of the third quarter of the year, the number of LLINs projected to be delivered by the end of 2013 will again increase, to 136 million. Assuming each net lasts 3 years, the 3-year running total of LLINs delayed by 1 year to account for the time from delivery to the country to distribution to households is a crude approximation of the number of LLINs available to households in a given year. The 3-year total of LLINs peaked in 2012 at 321 million nets, and the3-year total decreased in 2013 to 303 million. These totals are below the approximately 450 million LLINs required for all persons at risk to have access to a treated net in their household during the 3-year period. However, information on projected LLIN deliveries beyond 2013 suggests that the increase in deliveries in 2013 may continue and the 3-year total of available LLINs may increase. Countries conduct commodity-gap analysis, supported by the Roll Back Malaria (RBM) Partnership, as part of the strategic planning process.3 Through such analysis, country programmes reported that about 200 million LLINs have been
2. Manufacturers delivery information is for LLINs; therefore, delivered nets are referred to as LLINs. 3. Gap analysis as of September 2013 is available at http://www.rollbackmalaria.org/mechanisms/hwg.html 24 | WORLD MALARIA REPORT 2013

nanced by donors for 2014, which would bring the 3-year total of nets available in 2015 to more than 400 million, closer, though still below, to the number required for universal access.. NMCPs in the African Region reported using mass campaigns as the main ITN distribution channel during 2012, accounting for 89% of nets distributed, followed by antenatal care clinics (7%), immunization clinics (3%) and other channels (2%). Although more than 25 million ITNs were distributed through ANCs in Africa during the last three years, for many countries, the number of ITNs reportedly distributed through ANCs are lower than the number of rst ANC visits reported by national programmes. Comparing rst ANC visits and the number of ITNs distributed through ANCs for countries with consistent reporting for three years, national programmes distributed enough ITNs through ANCs to provide an ITN for 55% of women attending rst ANC visit; conversely, 45% of ANC visits were missed opportunities for distribution of an ITN. Similarly, comparing the number of ITNs reportedly distributed through EPI clinics with the number of EPI visits for rst dose of diphtheriatetanus-pertussis (DTP1) vaccine4, national programmes distributed enough ITNs through EPI to provide an ITN at 34% of visits during which DTP1 was administered; therefore 66% of DTP1 visits were missed opportunities for delivery of an ITN. Further investigation is needed to understand how distribution of ITNs through ANC and EPI clinics could be improved. Outside Africa, NMCP reports indicate that 60 million ITNs were distributed during 20102012, with 10 countries accounting for 75% of the total (India 9.2 million, Indonesia 6.1 million, Myanmar 5.4 million, Bangladesh 4.7 million, Afghanistan 4.3 million, Cambodia 3.6 million, Papua New Guinea 3.2 million, Haiti 3.0
4. http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tswucoveragedtp1.html

Figure 4.3 Proportion of ITN-owning households with and without enough ITNs for all occupants, 2010-2012
ITN-owning households with enough ITNs for all occupants ITN-owning households without enough ITNs for all occupants United Republic of Tanzania 2012 Mali 2010 Rwanda 2010 Madagascar 2011 Senegal 2011 Uganda 2011 Burkina Faso 2010 Malawi 2012 Burundi 2010 Mozambique 2011 Liberia 2011 Nigeria 2010 Democratic Republic of Timor-Leste 2010 Gabon 2012 Angola 2011 Zimbabwe 2011 Haiti 2012 Cameroon 2011 0%
ITN, insecticide-treated net Source: Household surveys

are not conducted frequently enough to provide annual estimates of ITN coverage. To obtain more up-to-date estimates of ITN coverage, it is possible to combine information from previous household surveys with data provided by manufacturers on the number of LLINs delivered to countries, and with data from NMCPs on the number of ITNs distributed within countries (4). Estimates modelled in this way, produced in collaboration with the Institute for Health Metrics and Evaluation for the World malaria report, show that the proportion of households in sub-Saharan Africa owning at least one ITN increased steadily, from 3% in 2000 to 56% (range 53%60%) in 2012, with the most dramatic increase occurring during 20052010 (Figure 4.2). The rate of increase in the estimated proportion of households owning at least one ITN has slowed recently; it decreased slightly, to 54% (range 49%60%), in 2013. The decrease is probably related to the lower number of ITNs delivered to countries during 2011 and 2012, coupled with attrition of ITNs (due to loss and physical degradation), which reduces the supply of available nets. However, the change in the point estimates from 2012 to 2013 is within the condence limits of the model estimates, and this most likely represents a plateau of ITN coverage. Increased LLIN deliveries in 2013 and an even higher number of nets nanced in 2014 hold promise that ITN ownership will increase further in the next 2 years. The proportion of the population with access to an ITN and the proportion sleeping under an ITN can be estimated from household ownership of at least one ITN, by comparing the relationship between these measures within individual household surveys.5 In 2013, the estimated proportion of the population with access to an ITN reached 42% (range 38%47%) and the proportion sleeping under an ITN reached 36% (range 33%-41%) (Figure 4.2). These levels of population access and proportion sleeping under an ITN imply that about 86% of people who have access to an ITN use the ITNs that are available to them. Estimates of ITN household ownership, population access to an ITN, and population sleeping under and ITN for each country in sub-Saharan Africa for 2014 are given in Annex 4. Further information on ownership and use of ITNs can be derived from countries for which recent household surveys are available. Among 18 countries with household surveys conducted during 20102012 (Figure 4.3), the proportion of households owning at least one ITN ranged from 18% to 91%, and the proportion of households with enough ITNs for all occupants ranged from 4% to 52%. In countries surveyed during 20102012, a median of 34% (interquartile range [IQR] 28%42%) of ITN-owning households had enough ITNs for all occupants. From 2003 to 2012, the proportion of household with enough ITNs for all occupants was slightly higher among surveys conducted during 20092012 (33%) than among those conducted during 20032008 (28%), and also higher among surveys in which household ITN ownership was >50% (similarly 33%28%), although neither of these dierences were statistically signicant (Figure 4.4). For universal access to ITNs to be achieved, an increase is needed in household ownership of ITNs and in the proportion of ITN-owning households with enough ITNs for all inhabitants.
5. Based on 48 household surveys conducted in Africa during 20032012: population access to an ITN regression line y=0.77x; population sleeping under an ITN y=0.67x0.03. WORLD MALARIA REPORT 2013 | 25

20%

40%

60%

80%

100%

Proportion

Figure 4.4 Proportion of housholds with enough ITNs for all occupants by proportion of households with at least one ITN, 2002--2012
Surveys 20092012
100%

Surveys 20022008

Proportion of households with enough ITNs for all occupants

80%

60%

40%

20%

0% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Proportion of households owning at least one ITN

ITN, insecticide-treated net Source: Household surveys, 60 conducted 2002-2012

million and Philippines 3.0 million). About 87% of ITNs outside Africa were reportedly distributed through mass campaigns, 6% through immunization clinics, 1% through antenatal clinics and 6% through other channels. Because the estimates of the need for vector control interventions outside Africa remain imprecise, in particular for areas with P. vivax transmission, it remains unclear what percentage of need is being covered by these 60 million ITNs distributed by NMCPs.

4.2.2 Trends in ITN ownership, access, and use

For populations at risk of malaria, the extent of household ownership of ITNs and population access and use of ITNs can best be measured through household surveys. However, such surveys

The proportion of the population with access to an ITN has risen as ownership of ITNs by households has increased, although the level of ITN access varies among countries. In surveys conducted during 20102012, the proportion of the population with access to an ITN in the household raged from 11% to 74% (Figure 4.5). The proportion of the population sleeping under an ITN generally paralleled the proportion with access to an ITN, and ranged from 7% to 65%, indicating that ITN use among the population who have access to one ITN is consistently high across countries. In these recent surveys, the median proportion of people who have access to an ITN and actually use it was 88%, similar
Figure 4.5 Proportion of the population with access to an ITN, and proportion of population, children under ve years old, and pregnant women sleeping under an ITN, 2010-2012
Population with access to an ITN Population sleeping under an ITN Children under 5 sleeping under an ITN Pregnant women sleeping under an ITN Cameroon 2011 Haiti 2012 Angola 2011 Zimbabwe 2011 Democratic Republic of Timor-Leste 2010 Gabon 2012 Nigeria 2010 Liberia 2011 Burkina Faso 2010 Mozambique 2011 Malawi 2012 Senegal 2011 Burundi 2010 Uganda 2011 Madagascar 2011 Mali 2010 Rwanda 2010 United Republic of Tanzania 2012 0%
ITN, insecticide-treated net Source: Household survey

to the proportion of use among population with access to an ITN derived from the ITN model discussed above. Use of ITNs is even higher in certain populations: in every country surveyed, the proportion of children under 5 years and of pregnant women sleeping under an ITN are both higher than the proportion of the population as a whole sleeping under an ITN. In summary, people in malaria-endemic countries make use of the nets that are available to them, and usage is particularly high among key vulnerable populations. Therefore, the main challenge is still to increase distribution of ITNs so that all those at risk have access to an ITN, while continuing to ensure high usage of ITNs in all populations, including key vulnerable groups. Key ITN coverage indicators for countries with recent household surveys are available in Annex 5.

4.3 IRS policy adoption and implementation

4.3.1 IRS policy adoption
Adoption and implementation of policies for IRS programmes by WHO region are shown in Table 4.2, and adoption of policies by country is shown in Annex 2A. IRS is recommended for control of malaria in 88 countries, 40 of which are in Africa; in 15 of these African countries, IRS may be used for control of epidemics. IRS is used in combination with ITNs in 57countries, 31 of which are in Africa. A total of 58 countries reported that monitoring of insecticide resistance is undertaken a gure that is lower than the number of countries implementing IRS. Insecticide resistance monitoring should be carried out in all countries in which malaria vector control activities with insecticides are conducted (e.g. including distribution of ITNs).

4.3.2 IRS coverage achieved

National programmes reported that 135 million people representing 4% of the global population at risk were protected by IRS in 2012. The proportion of the population protected by IRS increased substantially in the African Region during 20062008, and the increased coverage was maintained during 20092011, at 10%12% of the population at risk. In 2012, a total of 58 million people, or 8% of the population at risk, were protected (Figure 4.6). The overall decrease in IRS coverage in Africa from 2011 to 2012 may be accounted for by decreased numbers of people protected

20%

40% 60% Proportion

80%

100%

Table 4.2 Adoption of policies for IRS programmes by WHO region, 2012
Policy AFR AMR EMR EUR SEAR WPR Total

IRS is recommended by malaria control programme IRS is used for the prevention and control of epidemics IRS and ITNs used together for malaria control in at least some areas DDT can be used for IRS Insecticide resistance monitoring is undertaken Number of countries/areas with ongoing malaria transmission Number of countries/areas with ongoing Plasmodium falciparum transmission

40 15 31 9 37 44 43

18 9 11 0 5 21 18

9 4 4 6 9 9

10 4 5 1

6 6 6 2 10 9

88 38 57 10 58 97 88

5 5 0

3 10 9

AFR, African Region; AMR, Region of the Americas; DDT, dichlorodiphenyltrichloroethane; EMR, Eastern Mediterranean Region; EUR, European Region; IRS, indoor residual spraying; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports 26 | WORLD MALARIA REPORT 2013

by IRS in Ethiopia, Madagascar and Mozambique, although this decrease appears to have been partially oset by expanded IRS coverage in Ghana, Malawi and Nigeria. The coverage of IRS programmes in the Region of the Americas decreased during the same period, protecting 5 million people (representing 4% of the population at risk) in 2012, down from a peak of 9% of the population protected in 2009. The proportion of the population protected by IRS increased in the Eastern Mediterranean Region, due in large part to an increased number of people protected reported from Pakistan, reaching 14 million people (4% of the population at risk) in 2012. In the Western Pacic Region, nearly 5 million people (1%) were protected in 2012. IRS coverage by national programmes in the South-East Asia Region is largely driven by IRS coverage in India. Such coverage has varied little during the past 10 years, with 53 million people (4% of the population at risk) protected in 2012. As several countries in the European Region move towards elimination of malaria, IRS programmes are focused on much smaller populations at risk than in other regions, and the proportion of the population at risk protected by IRS is substantially higher, reaching 46% in 2012 (not shown in Figure 4.6). Information on the insecticide classes used for IRS in 2012 was provided by 58 of the 79 malaria-endemic countries that reported the use of IRS double the number of countries that reported on insecticide classes in 2011. Pyrethroids were the primary insecticides used, as reported by 46 of the 58 countries; carbamates were used by 13 of reporting countries, organophosphate compounds by 8 countries, and the organochlorine dichlorodiphenyltrichloroethane (DDT) by 6 countries.6 A total of 29 countries in the African Region reported information for 2011 and 2012 on insecticides used in IRS: in 15 countries a pyrethroid was the primary insecticide reported in 2011; 3 of these countries reported a nonpyrethroid as primary insecticide in 2012. A decreased number of countries using pyrethroids in 2012 compared to 2011 was also noted in IRS programmes supported by the PMI.7 Information on the extent to which households have been protected by at least one vector control method can be ascertained from household surveys. In surveys conducted in 14 countries (12 in Africa) during 20102012, the proportion of
6. The total number of countries reporting specic chemical agents is greater than the number of countries reporting, because countries could report up to three chemical agents used. 7. http://fightingmalaria.gov/technical/irs/PMI_IRS_Insecticide_ Trends_080112.xlsx

households fully protected by vector control (i.e. with enough ITNs for all occupants or sprayed by IRS in the past 12 months) ranged from 6% to 62% (Figure 4.7). An even higher proportion of households in these surveyed countries (range 20%94%) had been reached with at least one ITN or sprayed by IRS. Information from household surveys on household coverage of any vector control method is useful for programmes, although surveys are not available from every country for every year. To obtain more timely estimates on the proportion of the population at risk in each country protected by vector control intervenFigure 4.7 Proportion of households with at least one ITN or enough ITNs for all occupants and/or protected by IRS in the last 12 months, surveys from 14 countries, 2010-2012
Households with enough ITNs for all occupants and/or sprayed by IRS in the last 12 monts Households with at least one ITN and/or sprayed by IRS in the last 12 months Madagascar 2011 United Republic of Tanzania 2012 Senegal 2011 Uganda 2011 Mozambique 2011 Malawi 2012 Burkina Faso 2010 Liberia 2011 Burundi 2010 Nigeria 2010 Gabon 2012 Cameroon 2011 Zimbabwe 2011 Haiti 2012 0% 20% 40% 60% Proportion 80% 100%

ITNs, insecticide-treated nets; IRS, indoor residual spraying Source: Household surveys

Figure 4.6 Proportion of population at malaria risk protected by IRS, by WHO Region, 20022012
15% World

AFR

AMR

EMR

SEAR

WPR

10% Proportion 5% 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
AFR, African region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; IRS, indoor residual spraying; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

WORLD MALARIA REPORT 2013 | 27

tions, the proportion of the population protected by IRS reported by NMCPs can be combined with the estimated proportion of the population sleeping under an ITN as derived from household surveys and from reports from manufacturers and national programmes (see Section 4.2.2). Analysis of household-survey data reveals that about half of the people in IRS-sprayed households are also protected by ITNs (see Box 4.1); therefore, to estimate the proportion of the population protected by either ITNs or IRS, it is reasonable to add half the proportion of the population protected by IRS to the proportion sleeping under an ITN. Deriving an estimate for the proportion of the population protected by any vector control in this way for Africa in 2012, it is clear that the estimated coverage of vector control interventions varies among countries (Figure 4.8). More than 80% of the population was protected by vector control measures in Cabo Verde, Sao Tome and Principe, South Africa and Swaziland,, whereas more than 60% was protected in Ethiopia, Madagascar, Namibia, Sierra Leone, Tanzania and Zimbabwe. In Cabo Verde, Liberia, Namibia, Sao Tome and Principe, South Africa, Zambia and Zimbabwe, more than half of the population protected by vector control was covered by IRS.

certain specic foci of malaria transmission, including 6 countries in the African Region, 9 in the Region of the Americas, 4 in the Eastern Mediterranean Region, 4 in the European Region, 5 in the South-East Asia Region and 3 in the Western Pacic Region. Various larval control strategies were reported, and many countries engaged in more than one type of larval control activity. Among countries reporting on larval control, 15 countries reported activities involving habitat manipulation (temporary changes to vector habitats), and 6 reported some form of habitat modication (longlasting physical transformations to reduce vector larval habitats). Larval control through chemical larviciding was reported by 18 countries, and through biological larviciding by 13 countries. Reports from malaria-endemic countries give an indication of the range of larval control methods employed, although the scale of eorts was not quantied and the impact on the malaria burden in individual countries is not easily measured.

4.4 Larval control strategies

In a few specic settings and circumstances, WHO recommends that the core vector control interventions of IRS and ITNs may be complemented by other methods (e.g. mosquito larval source control, including environmental management). Larval control is appropriate and advisable only in settings where mosquito breeding sites are few, xed and ndable (i.e. easy to identify, map and treat) (5). In 2012, national programmes in 31 malaria-endemic countries worldwide reported information on the use of larval control in

4.5 Malaria vector insecticide resistance and the Global plan for insecticide resistance management
4.5.1 Implementation of the Global plan for insecticide resistance management
Vector control through ITNs and IRS is a core component of NMCPs today, and the success of these interventions depends on the continued eectiveness of the insecticides used. Currently, global malaria-control eorts rely heavily on a single class of insecticide: the pyrethroids. This class of insecticide is used in most IRS programmes, and it is the only insecticide used in WHO-recommended LLINs. However, increasing resis-

Box 4.1 Estimating the extent of overlap in coverage with vector control interventions
An upper limit for a combined coverage estimate can be obtained by assuming there is no overlap in the populations protected by IRS or by ITNs (i.e. the combined coverage for a particular country is obtained by adding the proportion protected by IRS and that protected by ITNs). A lower limit can be obtained by assuming that there is complete overlap in the population protected by IRS and the population protected by ITNs (i.e. the combined coverage would be equal to the higher of the two population proportions protected by ITNs or IRS). For a reasonable estimate on where in this range the population protected by both vector control method lies, it is necessary to know, in countries employing both methods, the extent to which the populations targeted for ITNs and IRS overlap. Information on the extent these interventions overlap is limited but can be obtained from household surveys. In 14 household surveys conducted between 2010 and 2012 that included information on ITN and IRS, 9% of households were sprayed with IRS and about 60% of those households owned at least one ITN (Figure Box 4.3). In one third of these IRS households with an ITN, there were enough ITNs for all occupants, whereas the remaining two thirds did not have enough ITNs for all occupants. Considering that population access to an ITN is 77% in all ITN-owning households and 100% in households with enough ITNs for all, in ITN-owning households without enough ITNs MALARIA for all, about 65% of household 28 | WORLD REPORT 2013 members have access to an ITN. Combining this information, 20% of IRS-sprayed households have all members protected by ITNs and 40% have two thirds protected; consequently, about half of the people in these IRS-sprayed households are protected by ITNs and IRS and half are protected by IRS alone..
Figure Box 4.1 Proportion of households sprayed with IRS, owning at least 1 ITN, owning enough ITNs for all, surveys from 14 countries, 2010-2012
100% 80% 60% 40% 20% 0%
All households All households All households sprayed by IRS sprayed by IRS sprayed by IRS and owning enough and owning ITNs for all at least one ITN occupants IRS sprayed IRS sprayed IRS sprayed households with households with households enough ITNs for not enough ITNs with no ITNs all occupants for all occupants

IRS, indoor residual spraying; ITN, insecticide-treated net Source: Household survey

Figure 4.8 Proportion of population at malaria risk protected by ITNs or IRS, sub-Saharan Africa, 2012

(7), and numerous national-level training sessions were held by WHO and by partners, including several in the African Region. Information collected during 20112012 by WHO regional oces from Member States (as part of development of the GPIRM) showed that resistance to at least one insecticide in one malaria vector in one study site has been identied in 64 countries worldwide. Most of these reports concerned resistance to pyrethroids. In follow-up to the eorts to collect information on insecticide resistance management to inform the GPIRM, the Global Malaria Programme (GMP) of the WHO is implementing a database for insecticide resistance monitoring reports from Member States. A preliminary report on data collected in 2013 will be available in 2014.

Not applicable No ongoing malaria transmission <25% 2550% 5080% 80+%

iii) Developing new and innovative vector control tools Several promising new insecticide formulations, new active ingredients and new vector control paradigms are in the pipeline, facilitated by product development partnerships (e.g. the Innovative Vector Control Consortium) and other research institutes, and commercial sector partners. To facilitate and guide the development of these new products and approaches, WHO established the Vector Control Advisory Group in 2013; this group is jointly managed by the GMP and the Neglected Tropical Disease unit of the WHO. iv) Filling in knowledge gaps on mechanisms of insecticide resistance and the impact of current insecticide resistance management approaches The Africa Network for Vector Resistance (ANVR) established by the WHO African Regional Oce in 2000 is a consortium of universities, research institutes and national programmes throughout the region. In January 2013, WHO convened the 12th annual meeting of the ANVR to update activities and research ndings, and to develop A roadmap for GPIRM implementation. WHO is managing implementation of a ve-country project, Implications of Insecticide Resistance, which is due to be completed at the end of 2014. v) Ensuring that key enabling mechanisms (advocacy as well as human and nancial resources) are in place In 2013, WHO issued guidance on capacity-building for entomology and vector control to address the human-resource crisis in these areas faced by many NMCPs. WHO is also working with partners including the Global Fund, RBM, foundations and donors to urgently build and nance country-level capacities to adequately respond to the threat of insecticide resistance.

IRS, indoor residual spraying; ITN, insecticide-treated net Source: ITN coverage model from the Institute for Health Metrics and Evaluation, which takes in account ITNs supplied by manufacturers, ITNs delivered by NMCPs and household survey results Proportion population sleeping under an ITN derived from relationship with household ownersh of at least one ITN analyzed by linear regression in 50 household surveys 2001-2012, y= 0.67x - 0 Proportion population protected by IRS from National Malaria Control Programme reports. Coverage estimate as of June 30, 2012. Map production: Global Malaria Programme (GMP), World Health Organization

tance of malaria vectors to pyrethroids and to other insecticides jeopardizes global malaria control eorts. Recognizing the threat posed by insecticide resistance, WHO released the Global plan for insecticide resistance management in malaria vectors (GPIRM) in May 2012 (6). The GPIRM summarizes the current status of insecticide resistance, the potential eect of resistance on the burden of malaria, and the available approaches to managing resistance; it also outlines a global strategy and action plan for insecticide resistance management for the global malaria community. The global strategy described in the GPIRM is based on ve pillars that relate to activities among dierent stakeholders in the global malaria community; recent developments in these activity areas are described below: i) Planning and implementing insecticide resistance management strategies Establishment of a national intersectoral committee is a key step in developing a robust national resistance management plan that includes more judicious use of insecticides, rotations and combinations of vector control interventions. In many countries, this is done through a previously established integrated vector management committee. In 2013, workshops were held in the African Region and the Eastern Mediterranean Region to support Member States in the development and roll out of these plans. ii) Ensuring proper, timely entomological and resistance monitoring and eective data management Timely resistance monitoring is still limited in many parts of malariaendemic countries, but progress is being made. In 2013, WHO published a revision of the insecticide resistance testing guidelines

4.5.2 Management of insecticide resistance in relation to IRS coverage

Overall protection of at risk populations with IRS decreased globally from 5% in 2011 to 4% in 2012; in the African Region the proportion protected by IRS decreased from 11% to 8% during the same time period (see section 4.3.2). The reasons for the decrease in IRS implementation are not clear. Some countries appear to have decreased use of pyrethroids and increased their use of non-pyrethroid insecticides, either in direct response to insecticide resistance monitoring data or as part of a plan to use insecticides in rotation to minimize the development of resistance. Since most of the non-pyrethroid insecticides used in
WORLD MALARIA REPORT 2013 | 29

rotation are more costly than pyrethroids, control programmes with funding constraints may have reduced the target population to be protected by IRS, and provided vector control coverage through ITNs in areas previously covered with IRS. The decrease in the number of persons protected by IRS can be interpreted as a sign that country programmes are actively managing their insecticide use. Active management of insecticide use in response to insecticide resistance monitoring data or planned rotational use of insecticides to minimize the development of resistance are recommended in the GPIRM. Indeed, a key objective of GPIRM was the preservation of the eectiveness of pyrethroids and other classes of insecticides until new tools become available. Since all currently available insecticide-treated mosquito nets are treated with pyrethroids, it is only through IRS that all classes of insecticides (including pyrethroids) can be used in rotation; consequently, the use of non-pyrethroids in IRS will continue to be an important insecticide resistance management tool for malaria control programmes. Rotational use of insecticides, guided by intensive insecticide resistance monitoring and analysis of resistance monitoring data, may allow for renewed use of pyrethroids in areas where they had been previously been deemed ineective (8).

IRS implementation are not clear for most programmes. One factor may be the relatively high cost (per person per year of protection) of IRS compared to ITNs (9, 10). Also, IRS costs may increase due to the change to a more expensive insecticide in response to insecticide resistance. Targeted use of IRS with nonpyrethroids may become increasingly important as an insecticide-resistant management tool, especially given that currently approved LLINs all use pyrethroids. Monitoring and management of insecticide resistance The eectiveness of both IRS and ITNs is threatened by the development of insecticide resistance. Monitoring and management of insecticide resistance for malaria control is set out in the recently released GPIRM. Activities recommended in the GPIRM are under way; however, more needs to be done to manage resistance by more active strategies using existing tools. Addressing insecticide resistance will be helped by the development of new insecticides (especially those appropriate for ITNs), and by the use of vector control and other interventions to reduce transmission that do not rely on insecticides.

References
1. Pluess B, Tanser FC, Lengeler C, Sharp BL. Indoor residual spraying for preventing malaria. Cochrane Database of Systematic Reviews, 2010, (4):CD006657. 2. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database of Systematic Reviews, 2004, (2):CD000363. 3. Report of the twelfth WHOPES working group meeting. Geneva, World Health Organisation, 2009 (http://whqlibdoc.who.int/ hq/2009/WHO_HTM_NTD_WHOPES_2009_1_eng.pdf, accessed 22 November 2013). 4. Flaxman AD, Fullman N, Otten MW, Menon M, Cibulskis RE, Ng M et al. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assistance for health: A systematic synthesis of supply, distribution, and household survey data. PLoS Medicine, 2010, 7(8):e1000328. 5. WHO interim position statement the role of larviciding for malaria control in sub-Saharan Africa. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/atoz/larviciding_ position_statement/en/index.html, accessed 15 October 2013). 6. Global plan for insecticide resistance management in malaria vectors. Geneva, World Health Organization, 2012 (http:// www.who.int/malaria/publications/atoz/gpirm/en/index.html, accessed 15 October 2013). 7. Test procedures for insecticide resistance monitoring in malaria vector mosquitoes. Geneva, World Health Organization, 2013 (http://www.who.int/malaria/publications/atoz/9789241505154/ en/index.html, accessed 15 October 2013). 8. Hemingway J, Vontas J, Poupardin, R, Raman J, Lines J, Schwabe C, Matias A, Kleinschmidt I. Country-level operational implementation of the Global Plan for Insecticide Resistance Management. Proc Nat Acad Science, 2013, 110(23):9397-9402. www.pnas.org/ cgi/doi/10.1073/pnas.1307656110 9. White MT, Conteh L, Cibulskis R, Ghani AC. Costs and cost-eectiveness of malaria control interventions--A systematic review. Malaria Journal, 2011, 10:337. 10. World malaria report 2011. Geneva, World Health Organization, 2011 (http://apps.who.int/iris/bitstream/10665/44792/2/978924156 4403_eng_full.pdf, accessed 22 November 2013).

4.6 Conclusions
Access to ITNs has increased, use of available ITNs remains high, but progress towards universal coverage targets stalled in 2012 Tremendous progress had been made in the past 10 years in the distribution of ITNs, especially in Africa, where it is estimated that more than half of all households in malaria-endemic areas had at least one ITN in 2013. Estimated access to an ITN and the proportion of the population sleeping under an ITN have also increased. However, ITN access remains well below the targets of universal coverage, and has not appreciably progressed in the past 2 years. There is high usage of nets among the population with access to them. In the most recent household surveys, about 88% of people with access to a net in their household reported sleeping under it the night before. Levels of use are even higher for certain vulnerable groups, including children under 5 years of age and pregnant women. Current eorts to encourage the use of nets should be maintained, as should eorts to increase the number of available nets within households. Progress towards achieving universal coverage stalled due to decreased numbers of ITNs delivered to countries during 2011 and 2012; however, the larger number of projected deliveries of nets in 2013 and the large number of nets currently nanced for delivery during 2014 suggest that ITN coverage should again increase over the next 2 years. Delivery of nets need to be sustained at or above current levels in order to achieve and maintain universal coverage targets. IRS coverage decreased globally in 2012 Several countries expanded their IRS programmes and others achieved high levels of vector control coverage through the distribution of ITNs and deployment of IRS. Nevertheless, overall protection of at-risk populations with IRS decreased globally from 2011 (5%) to 2012 (4%). The reasons for the decrease in
30 | WORLD MALARIA REPORT 2013

CHAPTER 5

Preventive therapies for malaria

This chapter reviews: (i) the adoption of policies and implementation of programmes for intermittent preventive treatment of malaria in pregnancy and in infants, and for seasonal malaria chemoprevention in children; and (ii) progress in the development of a malaria vaccine. living in the Sahel subregion could benet from SMC (2). Considering the substantial burden of malaria in groups targeted for preventive treatments, important reductions in infant and childhood morbidity and mortality could be achieved through expanded implementation of IPTp, IPTi and SMC. IPTp reduces low birth weight arising from malaria in pregnancy, which is estimated to result in as many as 100 000 infant deaths each year in sub-Saharan Africa (3). IPTi has been shown to reduce clinical malaria cases by 30% in the rst year of life. Implementation of SMC could reduce the approximately 108 000 deaths in children under 5 years of age with malaria estimated to occur during one year in areas of the Sahel targeted for this intervention (2).

5.1 Need for preventive chemotherapy

WHO currently recommends three highly cost-eective strategies for the use of antimalarial medicines for the prevention of morbidity, targeting groups at high risk of Plasmodium falciparum malaria, in areas of moderate to high malaria transmission in sub-Saharan Africa (see Chapter 2):

intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) (IPTp-SP), delivered at each scheduled antenatal care (ANC) visit after the rst trimester; intermittent preventive treatment in infants (IPTi) with SP (IPTi-SP), delivered at the time of the second and third diphtheriatetanuspertussis (DTP) and measles vaccination;1 and seasonal malaria chemoprevention (SMC) with amodiaquine plus SP (AQ+SP) for children aged 359 months in areas of highly seasonal malaria transmission across the Sahel subregion.2

5.2 Malaria chemoprevention policies and implementation

5.2.1 Intermittent preventive treatment of pregnant women
National adoption and implementation of policies for the use of antimalarial agents for malaria prevention are shown by WHO region in Table 5.1 and by country in Annex 2A. The countries that had adopted IPTp-SP as national policy by the end of 2012 include 36 high-burden countries in sub-Saharan Africa. In addition, IPTp-SP had been adopted and implemented in Papua New Guinea, in the WHO Western Pacic Region. Recommended indicators for monitoring implementation of IPTp have recently been updated to be in line with the revised policy that IPTp be given at every scheduled ANC visit after the rst trimester (see Table 2.2 in Chapter 2). The proportion of all pregnant women who receive one, two, three or four doses of IPTp can be derived from household surveys, and the proportion of pregnant women attending ANC who receive one, two, three or four doses can be obtained from health-facility reports. The revised WHO IPTp policy was not issued until late in 2012, and national malaria control programmes (NMCPs) are in the process of updating their national policies and data collection systems

For example, in 2012 it was estimated that, each year in malariaendemic areas of Africa, 35 million women who become pregnant3 could benet from IPTp and a large proportion of the approximately 26 million infants born4 could benet from IPTi; in addition, an estimated 25 million children aged 359 months
1. IPTi is recommended in areas where SP resistance is not high (dened as a prevalence of the pfdhps 540 mutation of < 50% in P. falciparum). 2. Countries in which SMC may be appropriate include Benin, Burkina Faso, Cameroon, Chad, Gambia, Ghana, Guinea, Guinea-Bissau, Mali, Mauritania, Senegal, Sierra Leone, Sudan, and Togo. 3. Projected using crude birth rates of endemic countries and pregnancy-tobirth ratios from Dellicour et al. (2010) (1). 4. Projected using crude birth rates of endemic countries.

Table 5.1 Adoption of policies for preventive treatments (IPTp, IPTi, SMC), by WHO Region, 2012
Policy AFR AMR EMR EUR SEAR WPR Total

IPTp used to prevent malaria during pregnancy IPTi to prevent malaria in infants Seasonal malaria chemoprevention Number of countries/areas with ongoing transmission Number of endemic countries/areas with ongoing transmission of P. falciparum

34 1 2 44 43

N/A N/A N/A 21 18

2 N/A N/A 9 9

N/A N/A N/A 5 0

N/A N/A N/A 10 9

1 N/A N/A 10 9

37 1 2 99 88

AFR, African Region; AMR, Region of the Americas; DDT, dichlorodiphenyltrichloroethane; EMR, Eastern Mediterranean Region; EUR, European Region;IPTi, intermittent preventative treatment in infants; IPTp, intermittent preventative treatment in pregnancy; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports WORLD MALARIA REPORT 2013 | 31

Figure 5.1 Proportion of all pregnant women receiving IPTp, by number of doses received, 20102012
IPTp 1 Malawi 2012 Burkina Faso 2010 Senegal 2011 United Republic of Tanzania 2012 Liberia 2011 Uganda 2011 Cameroon 2011 Mozambique 2011 Angola 2011 Madagascar 2011 Nigeria 2010 Zimbabwe 2011 Gabon 2012 0% 20% 40% 60% 80% Proportion of pregnant women 100% IPTp 2 IPTp 3 IPTp 4

for IPTp; hence, information on IPTp implementation through 2012 described in this chapter reects experience with the previous IPTp policy, which recommended at least two doses of SP for IPTp during the second and third trimesters of pregnancy. Information on the proportion of all pregnant women receiving IPTp can be derived from household surveys. In most standard household surveys, respondents are asked about each dose of SP for IPTp received, making it possible to calculate the proportion of pregnant women who received one, two, three or four doses. Data were available on IPTp from 67 surveys in 31 countries between 1999 and 2012. In surveys conducted during 20102012, a higher proportion of pregnant women received one dose of SP for IPTp than received two, three or more doses (Figure 5.1). The proportion of pregnant women who received three or more doses of IPTp ranged from 1% to 22%. The population-weighted average of the proportion of pregnant women who received three doses of IPTp across surveyed countries was low (8%), which is not surprising given that these data represent implementation before the IPTp policy was revised. Twenty-three per cent of women received two doses, and 37% received at least one dose; these proportions are low, considering that IPTp with at least two doses has been recommended in most sub-Saharan African countries for many years. A recent review of interventions for malaria in pregnancy used available survey data from 20092011, weighted by the estimated number of pregnancies per country (4). The review estimated, for 2010, similar levels of IPTp delivery: 22% of all pregnant women and 26% of women who had attended ANC at least twice had received two doses of IPTp. Data collected and reported by NMCPs provide information on the receipt of IPTp among pregnant women who attend ANC in the public sector. Of the 36 NMCPs that had IPTp as national policy in 2012, 26 programmes reported data on both the dose of IPTp (numerator) and the number of women who had attended ANC at least once (denominator). In these reporting countries, a median of 64% of women attending ANC in 2012 received one dose of IPTp, and 38% received two doses (Figure 5.2). Among the six countries with information on three or more doses of IPTp received, a median of 23% (range 244%) of pregnant women attending ANC at least once received three or more doses. The low rates of IPTp coverage among pregnant women in settings where a high proportion of pregnant women attend ANC suggests that a large number of opportunities are missed for delivering recommended preventive treatment during ANC (see Box 5.1).

IPTp, intermittent preventive treatment in pregnancy Source: Household surveys

Figure 5.2 Proportion of women attending antenatal care receiving IPTp, by number of doses received, 2012
IPTp 1 Central African Republic Gambia Togo Sao Tmoe and Principe Zambia Sierra Leone Guinea Cameroon Mali Ghana Congo Burkina Faso Democratic Republic of the Congo Liberia Mozambique Madagascar Angola Comores United Republic of Tanzania Mauritania Equatorial Guinea Benin Zimbabwe Guinea-Bissau Kenya Malawi 0% 20% 40% 60% 80% Proportion of pregnant women 100% IPTp 2 IPTp 3

5.2.2 Intermittent preventive treatment of infants

IPTi is the administration of a therapeutic dose of SP, delivered through immunization services at dened intervals corresponding to routine vaccination schedules usually at 10 weeks, 14 weeks, and approximately 9 months of age to those at risk of malaria. Studies show that IPTi delivered through Expanded Programme on Immunization (EPI) services provides protection in the rst year of life against clinical malaria and anaemia, and reduces hospital admissions for infants with malaria and admissions for all causes. Hence, WHO recommends IPTi in sub-Saharan African countries with moderate-to-high malaria transmission, and with low levels of parasite resistance to SP.

IPTp, intermittent preventive treatment in pregnancy Source: National Malaria Control Programme reports

32 | WORLD MALARIA REPORT 2013

WHO published IPTi implementation guidelines in September 2011 (6). In 2012, only Burkina Faso had adopted IPTi as national policy, but it had not started implementation.

5.2.3 Seasonal malaria chemoprevention

SMC, previously termed IPT in children, is dened as the intermittent administration of full treatment courses of eective antimalarial regimens during the malaria season to prevent malarial illness, with the objective of maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk. SMC has been studied in areas where the main risk of clinical malaria is restricted to a few months each year, and the main burden of malaria is in children, rather than in infants. In these settings, SMC has been shown to prevent about 75% of uncomplicated and severe malaria episodes. An implementation manual for SMC, developed by the WHO Global Malaria Programme (GMP) with the support of partners, was issued in December 2012. (7) In 2012, two countries reported

adopting the policy of SMC; in 2013, nine countries in the Sahel subregion are at an advanced stage of nalizing the adoption of SMC as policy (Burkina Faso, Chad, Gambia, Ghana, Mali, Niger, Nigeria, Senegal and Togo). All but four of these countries (Burkina Faso, Gambia and Ghana) have started small-scale implementation in a few districts with support from partners, and in two cases with funding from the national government. The major barrier to rapid scale-up of SMC in all of these countries has been the diculty of mobilizing the required resources early enough before the start of the 2013 malaria transmission season.

5.3 New therapies for malaria prevention

5.3.1 Malaria vaccine development
An eective vaccine against malaria has long been envisaged as a valuable addition to the available tools for malaria control.

Box 5.1 Missed opportunities in the delivery of IPTp

Household surveys make it possible to analyse the delivery of IPTp in relation to attendance at ANC. Such attendance is high in most sub-Saharan African countries: among nine countries with available surveys during 20102012, approximately 95% of pregnant women attended ANC at least once, 92% at least twice, and 80% and 51% made three and four visits respectively (Figure Box 5.1a). The proportion who received one IPTp dose was 48%, two doses 27%, three doses 11% and four doses 1.0%. Given the gap between the proportion of pregnant women attending ANC and the proportion receiving IPTp, a substantial number of ANC visits appear to represent missed opportunities for delivery of IPTp. One can quantify the extent of missed opportunities for IPTp delivery by subtracting the number of IPTp doses received from the number of ANC visits made by each pregnant woman. Even making the conservative assumption that all initial ANC visits occurred in the rst trimester when IPT is not given (and thus subtracting one from the recorded number of ANC visits), the number of ANC visits representing missed opportunities for IPTp is large. In the nine recently surFigure Box 5.1a Proportion of pregnant women attending ANC and proportion receiving IPTp, by number of ANC visits and IPTp dose, in nine Africa countries, 20102012
100%

veyed countries, a median of 72% of ANC visits represented missed opportunities to deliver IPTp. Several barriers to the delivery of IPTp at health facilities have been identied, including unclear policy and guidance regarding IPTp, stockouts of medication, and health worker confusion regarding the timing of IPTp dosing (5). Although some of the identied barriers involve larger health-system deciencies, many appear amenable to improvement with focused interventions, especially implementation of the revised WHO policy recommendation. To understand the potential for improving delivery of IPTp, it is useful to compare delivery of SP for IPTp to another service delivered during pregnancy, through ANC, such as administration of tetanus toxoid (Figure Box 5.1b). In most countries surveyed in 20002012 with information on both IPTp and receipt of tetanus toxoid, a substantially higher proportion of pregnant women received at least 2 doses of tetanus toxoid (median 56%, interquartile range [IQR] 4364%) than at least 2 doses of IPTp (median 10%, IQR 428%). Overall, it appears that the ability to administer certain preventive services during ANC is high in most ANC clinics, and that barriers to delivering SP for IPTp can be overcome.
Figure Box 5.1b The proportion of pregnant women who received at least 2 doses of tetanus toxoid and the proportion who received at least two doses of IPTp during pregnancy, 20002012
Surveys 20102013
100%

Surveys 20032008 y=x

Proportion of pregnant women who received at least 2 doses of IPTp during pregnancy

80%

80%

Proportion of women

60%

60%

40%

40%

20%

20%

0%

ANC 1 IPTp 1

ANC 2 IPTp 2

ANC 3 IPTp 3

ANC 4 IPTp 4

0% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ANC, antenatal care; IPTp, intermittent preventive treatment in pregnancy Source: Household surveys in Benin, Cameroon, Gabon, Mozambique,Malawi, Senegal, Tanzania, Uganda, Zimbabwe

Proportion of pregnant women who received at least 2 doses of tetanus toxoid during pregnancy
IPTp, intermittent preventive treatment in pregnancy Source: Household surveys

WORLD MALARIA REPORT 2013 | 33

Although research towards the development of malaria vaccines has been pursued since the 1960s, as yet there are no licensed malaria vaccines. However, a number of candidate vaccines are being evaluated in clinical trials, with one candidate vaccine currently being assessed in Phase 3 clinical trials (RTS,S/AS01) (8), and about 20 others in Phase 1 or Phase 2 clinical trials.5 Vaccine candidate RTS,S/AS01 The RTS,S/AS01 vaccine targets P. falciparum. Now in Phase 3 clinical trials, the vaccine is being developed in a partnership between GlaxoSmithKline (GSK) and PATH Malaria Vaccine Initiative (MVI), with MVI receiving funds from the Bill & Melinda Gates Foundation. The vaccine comprises a fusion protein of a malaria antigen the carboxy terminus of the P. falciparum circumsporozoite (CS) antigen with hepatitis B surface antigen, and includes a new and potent adjuvant. The manufacturers clinical development plan for the vaccine focuses on infants and young children living in malaria-endemic African countries. In October 2013, a third set of results on the ecacy of the RTS,S/ AS01 vaccine were reported for 614 week and 517 month age groups (9). In the 517 month age group, ecacy estimates, pooled across all trial sites, remained statistically signicant against clinical malaria (46%) and severe malaria (35.5%). Reductions in both malaria hospitalizations (41.5%) and all-cause hospitalizations (19%) were noted over 18 months. By contrast, at 27% in the 614 week age group, the ecacy estimate for severe malaria was not statistically signicant (although ecacy against clinical malaria remained statistically signicant). In the 517 month age group, site-specic ecacy was demonstrated in all 11 settings in seven African countries. The site-specic ecacy estimates over 18 months of follow-up ranged from 40% to 77%, with statistical signicance at all sites. By contrast, statistically signicant ecacy was conrmed at four of the 11 sites in the younger 614 week age group. The reasons for this dierence between the age groups are unclear, but co-administration with DTP-containing vaccines and the presence of maternally acquired antibodies to malaria may contribute to a lower immune response in infants aged 614 weeks. The full Phase 3 trial results will become available to WHO in late 2014 and will include 30 months of follow-up safety and ecacy data from groups of children aged 614 weeks and 517 months, together with data on ecacy and safety of an 18-month booster dose and site-specic ecacy. The WHO Joint Technical Expert Group on Malaria Vaccines (together with the Global Malaria Programme and Department of Immunization, Vaccines and Biologicals), has advised that, in the light of the results published to date, a policy recommendation could be considered once the full trial results become available. The timelines of the Phase 3 trial may allow a WHO review and recommendation in late 2015, as a potential addition to the current WHO-recommended malaria preventive measures. The WHO process for review will also depend on the timings and outcome of the regulatory review that will be performed by the European Medicines Agency in 20142015. Any possible recommendation related to vaccination in the

517 month age group would require at least two visits to be added to the routine immunization schedule. Other malaria vaccine candidates in development Several other vaccine candidates are currently being explored, but their development is at least 510 years behind that of RTS,S/AS01. Details are provided in The Rainbow Tables: WHOs comprehensive spreadsheets of global malaria vaccine project activity, which are updated every 6 months. In November 2013, WHO and the malaria vaccine funders group launched an update to the Malaria Vaccine Technology Roadmap,6 with two new strategic goals. These goals are the development of highly ecacious vaccines to prevent malaria disease and deaths, and of vaccines designed to interrupt malaria transmission and contribute towards the long-term aim of malaria eradication. The revised goals also expand the roadmap to include P. vivax as well as P. falciparum.

5.4 Conclusions
Monitoring IPTp uptake following revised WHO IPTp policy The key indicators for monitoring uptake of IPTp have been revised following updated WHO recommendations that IPTp be given at every scheduled ANC visit after the rst trimester. IPTp indicators include the proportion of pregnant women who receive one, two, three and four doses among all pregnant women and those attending ANC.. Data to calculate these revised indicators are currently available from nationally representative household surveys and from several national programmes. Many programmes need to update their reporting systems to obtain the necessary data to monitor progress in implementing IPTp according to the revised policy. Missed opportunities for IPTp implementation Although the benets of IPTp have been well established, implementation of IPTp has lagged in comparison to that of other malaria control interventions. In recently conducted household surveys in nine countries, about 37% of all pregnant women received one dose of IPTp, 23% two doses and 8% three doses. Among 26 countries reporting on IPTp delivered to pregnant women attending public ANC, about 64% received one dose, 38% two doses and 23% three doses of IPTp. Analysis of household survey data suggests that, even accounting for ANC visits during the rst trimester when IPTp is not given, an opportunity to give SP for IPTp is missed at about 70% of ANC visits. The high level of missed opportunities to deliver IPTp at ANC delivery compared to the delivery of other preventive interventions (e.g. administration of tetanus toxoid to pregnant women) suggests that it would be best to focus eorts to overcome barriers to IPTp implementation at the ANC level. Implementation of IPTi and SMC The slow uptake of IPTi as new policy and the lack of implementation of this policy highlight the challenges of adopting new control strategies, even where an established system for delivery of preventive services, such as EPI, exists. Adoption and
6. www.who.int/immunization/topics/malaria/vaccine_roadmap

5. See http://who.int/malaria/areas/vaccine/en/index.html 34 | WORLD MALARIA REPORT 2013

implementation of SMC appears to be more rapid than that of IPTi, even though implementation of SMC cannot rely solely on existing service delivery structures. In countries for which IPTi and SMC are recommended, implementation of SMC may take precedence over IPTi because of its greater estimated impact, given that it is not recommended that these interventions be implemented together.

References
1. Dellicour S, Tatem AJ, Guerra CA, Snow RW, ter Kuile FO. Quantifying the number of pregnancies at risk of malaria in 2007: A demographic study. PLoS Medicine, 2010, 7(1):e1000221. 2. Cairns M, Roca-Feltrer A, Garske T, Wilson AL, Diallo D, Milligan PJ et al. Estimating the potential public health impact of seasonal malaria chemoprevention in African children. Nat Commun, 2012, 3:881 (http://dx.doi.org/10.1038/ncomms1879, accessed 11 November 2013). 3. Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis, 2007, 7(2):93104. 4. van Eijk AM, Hill J, Larsen DA, Webster J, Steketee RW, Eisele TP et al. Coverage of intermittent preventive treatment and insecticidetreated nets for the control of malaria during pregnancy in subSaharan Africa: A synthesis and meta-analysis of national survey data, 200911. Lancet Infect Dis, 2013, S1473-3099(13):7019970193 (http://www.ncbi.nlm.nih.gov/pubmed/24054085, accessed 11 November 2013). 5. Hill J, Hoyt J, van Eijk AM. Factors aecting the delivery, access and use of intermittent preventive treatment and insecticide treated nets among pregnant women in sub-Saharan Africa: A systematic review. PLoS Medicine, 2013, 10:e1001488. 6. Intermittent preventive treatment for infants using sulfadoxine-pyrimethamine (SP-IPTi) for malaria control in Africa: Implementation eld guide. Geneva, World Health Organization (WHO) Global Malaria Programme (GMP) and Department of Immunization, Vaccines and Biologicals (IVB) and United Nations Childrens Fund (UNICEF), 2011 (http://whqlibdoc.who.int/hq/2011/WHO_ IVB_11.07_eng.pdf, accessed 15 October 2013). 7. Seasonal malaria chemoprevention with sulfadioxine-pyrithamine plus amodiaquine in children, a eld guide. Geneva, World Health Organization (WHO), 2012. 8. Agnandji ST, Lell B, Fernandes JF, Abossolo BP, Methogo BG, Kabwende AL et al. A Phase 3 trial of RTS,S/AS01 malaria vaccine in African infants. N Engl J Med, 2012, 367(24):22842295 (http:// www.ncbi.nlm.nih.gov/pubmed/23136909, accessed 11 November 2013). 9. Otiene, C, for the RTS,S Clinical Trials Partnership. Ecacy of RTS, S/ AS01 Vaccine Candidate against malaria in African infants and children 18 months post-primary vaccination series: a phase III randomized double blind controlled trial (abstract). Multinational Initiative on Malaria, 6th Pan African Malaria Conference, Durban, South Africa, October 6-11, 2013.

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36 | WORLD MALARIA REPORT 2013

CHAPTER 6

Diagnostic testing and treatment of malaria

This chapter reviews: (i) the needs for malaria diagnostic testing and treatment; (ii) the adoption of policies and implementation of programmes to expand access to, and use of, universal diagnostic testing of suspected malaria cases; (iii) the adoption of policies and implementation of programmes to expand access to, and use of, eective treatment for malaria; (iv) the progress made in withdrawing oral artemisinin-based monotherapies from the market; (v) the current status of drug ecacy monitoring and the latest trends in antimalarial drug resistance; and (vi) eorts to contain artemisinin resistance. malaria (4). For this analysis, we assume that all conrmed cases and all suspected cases not tested are treated for malaria. The proportion of suspected malaria cases tested at public facilities can be calculated from national programme data. There is less information on malaria testing in the private sector; however, based on data from available household surveys (see Section 6.2.3), the proportion tested in the private sector can be derived from the rate in the public sector. Treatment needs for P. falciparum and P. vivax infections can be calculated by considering the proportion of cases due to each species, based on country-reported testing data. Estimated in this way, the estimated number of diagnostic tests needed annually for suspected malaria cases is large, at over 1 billion globally; in the African Region, this need is estimated at around 600 million (range 392825 million). Treatment needs based on current levels of diagnostic testing are also large, with an estimated 479 million (range 312656 million) ACT treatments needed in the African Region alone. If all suspected cases were tested, and only conrmed malaria cases were treated with ACTs, the need for malaria treatment would be dramatically reduced. For example, in the African Region, if universal testing of all suspected malaria cases were implemented, the need for ACT treatments would be reduced by more than 60%. These estimates are intended to illustrate the magnitude of diagnostic and treatment needs on a regional and global scale, and the potential impact of implementing universal diagnostic testing, rather than being absolute needs for programme procurement purposes. Uncertainty limits around these diagnostic and treatment need estimates are large, because they are derived from similarly uncertain malaria case estimates and other data inputs. The diagnostic needs calculated here for the African Region, for example, may underestimate the true diagnostic needs, because the test positivity rates derived from reported national programme data used in this analysis are higher than those derived from published studies (5). For full implementation of a universal diagnostic testing policy for suspected malaria, patients with suspected malaria must seek care delivered by trained health-care providers in the public or private sector, or at the community level. Household survey data from 69 countries from 1990 to 2012 show that, across WHO regions, a median of 20%50% of children were not brought for care for a recent fever. Among countries in the African Region, a higher proportion (median 38%) of febrile children sought care in the public sector (public facilities or community programs) than in the private sector (private clinics or shops), where the median was 17%.
WORLD MALARIA REPORT 2013 | 37

6.1 Needs for diagnostic testing and treatment

WHO recommends that all persons of all ages in all epidemiological settings with suspected malaria should receive a parasitological conrmation of diagnosis by either microscopy or rapid diagnostic test (RDT), and that uncomplicated Plasmodium falciparum malaria should be treated with an artemisinin-based combination therapy (ACT) (1). Diagnostic testing for malaria is the cornerstone of WHOs initiative T3: Test. Treat. Track whereby testing of every suspected malaria case ensures appropriate antimalarial treatment and improves malaria surveillance. WHO provides guidance for quantifying (at the national programme level) diagnostic needs using malaria surveillance data (2), and treatment needs based on malaria morbidity (3). These data can be used to assess the scale of global and regional diagnostic and treatment needs. The total number of suspected malaria cases that would require a malaria diagnostic test can be estimated by WHO region, by dividing the estimated number of malaria cases (Chapter 8, Section 8.3.1) by the malaria diagnostic test positivity rates derived from national programme data. Treatment needs for malaria depend in part on the extent to which malaria diagnostic testing is employed. If diagnostic testing were universally applied, the number of malaria cases from malaria burden estimates could be taken as representing the number of cases requiring treatment. However, to account for current levels of diagnostic testing in assessing malaria treatment needs, it is necessary to examine several factors: the proportion of patients with suspected malaria presenting for care in the public health sector or the private sector, and the proportion not seeking care; the proportion of patients with suspected malaria who receive a diagnostic test in each sector; and the proportion of people tested who have conrmed

6.2 Diagnostic testing for malaria

6.2.1 Policy adoption
National adoption and implementation of policies for parasitological conrmation of diagnosis of malaria by WHO region are shown in Table 6.1, and by country in Annex 2A. In 2012, 41 of 44 malaria-endemic countries in the African Region reported adoption of a policy of parasitological diagnosis for all age groups an increase of 6 countries since 2009. In other regions, a policy of universal diagnostic testing was adopted in 49 of 55 endemic countries. Malaria diagnosis is reportedly provided free of charge in the public sector in 85 countries across all regions. Use of combination RDTs that can detect more than one species of Plasmodium has been adopted as policy by 40 countries globally, among 47 countries that report more than one Plasmodium species. A total of 26 African countries are now deploying RDTs at the community level, as are 22 countries in other regions.

in 2005 to more than 108 million in 2012 (Figure 6.2). Most of the RDTs delivered in 2012 (78%) were used in the African Region, followed by the South-East Asia Region (16%) and Eastern Mediterranean Region (3%). These totals underestimate the total quantity of RDTs distributed (they represent public sector distributions only, and there is incomplete reporting only 32 of the 44 endemic countries in the African Region reported these data in 2012); however, the same upward trend is seen as for RDT sales, with the highest growth occurring in the African Region. Microscopic examinations undertaken The number of microscopic examinations for malaria reported by national malaria control programmes increased to a peak of 188 million globally in 2012 (Figure 6.3). The global total is dominated by India, which accounted for over 120 million slide examinations in 2012. The global increase in microscopy from 2011 to 2012 is accounted for by the nearly 52 million examinations undertaken (a 42% rise) from Africa. Several countries in Africa reported increased microscopy in 2012, with seven countries accounting for 85% of the increase.

6.2.2 RDTs procured and distributed, and microscopic examinations undertaken

RDTs procured For 2013, a total of 31 manufacturers that have participated in the WHO Malaria RDT Product Testing Programme during 20082012 have supplied data on RDT sales to public and private sectors in malaria-endemic regions (Figure 6.1). Sales have increased dramatically over the past 5 years for both P. falciparum-specic tests and combination tests that can detect more than one species reaching 205 million in 2012. WHO and other organizations (Centers for Disease Control and Prevention [CDC], Foundation for Innovative New Diagnostics [FIND], Special Programme for Research and Training in Tropical Diseases [TDR]), have undertaken product-quality testing. Results show an improvement in test quality over time (6); they also indicate that information on test quality is being used, because organizations funding diagnostic testing programmes are procuring proportionally more high-quality tests over time. RDTs distributed The reported number of RDTs delivered by national malaria control programmes (NMCPs) provides information on where RDTs procured from manufacturers are deployed in the public sector. The number has increased rapidly, from less than 200 000

6.2.3 Parasitological testing in the public sector, private sector and community
Parasitological testing in the public sector The proportion of reported suspected cases receiving a parasitological test can be calculated from information on testing and malaria cases reported by NMCPs. The number of suspected malaria cases may be reported directly, or can be derived from the reported number of presumed and conrmed malaria cases (5). A regional testing rate is calculated using data from countries reporting sucient data each year.1 The proportion of suspected cases tested in the public sector is highest in the Region of the Americas and the European Region, followed by the South-East Asia Region and the Western Pacic Region (Figure 6.4). The proportion of suspected cases tested in the public sector has risen steadily in the Western Pacic Region over the past 5 years. The
1. If countries report conrmed malaria cases only, then the number of suspected malaria cases equals the number of malaria diagnostic tests performed, and the proportion tested is xed at 100%. However, these values are not informative for assessing diagnostic testing eorts; therefore, the analysis does not include country reports for the years in which only conrmed cases are reported.

Table 6.1 Adoption of policies for malaria diagnosis by WHO Region, 2012
Policy AFR AMR EMR EUR SEAR WPR Total

Patients of all ages should undergo diagnostic test Malaria diagnosis is free of charge in the public sector Combination RDTs available in public sector RDTs used at community level Number of countries/areas with ongoing malaria transmission Number of P. falciparum endemic countries/areas Number of P. vivax endemic countries/areas Number of countries/areas endemic for both P. falciparum and P. vivax

41 33 17 26 44 43 7 6

21 21 9 8 21 18 20 17

7 8 1 2 9 9 6 6

5 5

8 10 6 7

8 8 7 5 10 9 10 9

90 85 40 48 99 88 58 47

5 0 5 0

10 9 10 9

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; NMCP, National Malaria Control Programme; RDT, rapid diagnostic test; SEAR, South-East Asia Region; WPR, Western Pacic Region 38 | WORLD MALARIA REPORT 2013

value for the South-East Asia Region is heavily inuenced by India, where the proportion of suspected cases receiving a diagnostic test is very high; without India, the proportion in 2012 drops from 99% to 56%. The testing rate in the Eastern Mediterranean Region has varied over the past decade, though it has risen steadily from 49% to 63% in the past 5 years. The proportion of suspected malaria cases tested in the public sector in the African Region has increased dramatically in the past 2 years, from 37% in 2010 to 61% in 2012 a period of time during which 39 of 44 malaria-endemic African countries reported, including 8 of the 10 highest burden countries in the region. Globally, the proportion of suspected cases receiving a diagnostic test in the public sector (among countries with sucient data to make this assessment)
Figure 6.1 RDT sales to public and private sectors, 20082012
Combination RDTs P. falciparum RDTs

increased from 44% in 2010 to 64% in 2012. The recent increase in testing in the African Region is due to both an increase in microscopy performed and an increase in the use of RDTs, which accounted for 40% of all tested cases in 2012. The reported testing rate may overestimate the true extent of diagnostic testing in the public sector, because, among other factors, it relies on accurate reporting of presumed malaria cases. Reporting bias, whereby countries with higher testing rates have a greater propensity to report, appears to be small; for example, in the African Region, the proportion of suspected cases tested among 7 countries reporting sucient data consistently since 2001 was slightly higher (67%) than the proportion among 31 countries reporting consistently since 2010 (60%).
Figure 6.2 RDTs distributed by NMCPs, by WHO region, 20052012
120 RDTs distributed (millions) 100 80 60 40 20 0
2005 2006 2007 2008 2009 2010 2011 2012

AFR AMR EMR EUR SEAR WPR

250
RDTs sold (millions)

200 150 100 50 0 2008 2009 2010 2011 2012

CDC, Centers for Disease Control; FIND, Foundation for Innovative New Diagnostics; RDT, rapid diagnostic test Source: Data provided by 31 (2008-2010), 24 (2011), 24 (2012) manufacturers eligible for the WHO FIND/CDC Malaria RDT Product Testing Programme

RDTs distributed in the European Region and the Region of the Americas are a very small fraction of the number distributed in other WHO Regions AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; NMCP, National Malaria Control Programme; RDT, rapid diagnostic test; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

Figure 6.3 Number of microscopic examinations performed for malaria, by WHO region, 20102012
200 180 160 140 120 100 80 60 40 20 0 AFR AMR EMR EUR SEAR WPR Microscopic examinations (millions)

Figure 6.5 Proportion of febrile children who had a blood test, by health sector, countries with available survey data, 20102012
Public sector Private sector Liberia 2011 Mozambique 2011 Rwanda 2010 Malawi 2012 Uganda 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

United Republic of Tanzania 2012 Burundi 2010 Haiti 2012

Figure 6.4 Proportion of suspected malaria cases attending public health facilities that receive a diagnostic test, 2000--2012

Gabon 2012 Senegal 2011 Madagascar 2011 Zimbabwe 2011 Nigeria 2010 Burkina Faso 2010

AFR

AMR

EMR

EUR

SEAR

WPR

100% Proportion of suspected cases receiving diagnostic test 80% 60% 40% 20% 0%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0%

20%

40% 60% Proportion

80%

100%

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; RDT, rapid diagnostic test; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

Public sector includes government and non-prot facilities, and community health workers; Private sector includes private clinics and providers, pharmacies, shops and traditional providers. Source: Household surveys

WORLD MALARIA REPORT 2013 | 39

Parasitological testing in the private sector Data reported by NMCPs on the number of RDTs distributed and patients examined by microscopy or RDTs generally cover the public sector only. However, about 40% of patients with suspected malaria worldwide seek treatment in the private sector, which includes regulated health facilities, and pharmacies and other retail outlets (4). Information on the extent of parasitological testing in the private sector is limited, but some may be derived from household surveys. Among 14 household surveys conducted during 20102012, the proportion of children under 5 years of age who received a diagnostic test for suspected malaria was lower in the private sector (median across surveys 11%, IQR 6%19%) than in the public sector (median across surveys 32%, IQR 18%42%)) (Figure 6.5). Due to a large proportion of children in surveyed countries who did not seek care, only a low proportion (median 18%) of all febrile children those who were brought for care in the public or private sector, and those who were not brought for care received a parasitological test for malaria. Malaria diagnostics in the community A total of 46 countries reported deployment of RDTs at the community level, and 15 million patients were tested in 2012, including 13 million tested with RDTs in India. Outside India, the countries reporting the largest numbers of patients tested with RDTs in the community included Myanmar (514 000), Viet Nam (207 000 tested) and Niger (185 000). Overall, patients tested with RDTs in the community represent a relatively small proportion (6%) of the reported total number of patients who received a parasitological test. RDTs are increasingly used for diagnostic testing of malaria in health facilities, including for the diagnosis of P. vivax (Box 6.1).

for rst-line treatment in 79 of 88 countries where P. falciparum is endemic; chloroquine is still used in some countries in the Region of the Americas where it remains ecacious. Pre-referral treatment of severe malaria cases with quinine or artemether intramuscularly (IM), or with artesunate suppositories, has been adopted by 33 countries in the African Region and by 52 countries globally. Of the 58 countries with ongoing P. vivax transmission, 52 countries adopted a policy of using primaquine for radical treatment of P. vivax cases; in 26 of these 52 countries directly observed primaquine treatment is recommended and 13 of these 47 countries recommend testing for glucose6-phosphate dehydrogenase (G6PD) deciency before treatment with primaquine.

6.3.2 Quantity of ACTs procured and distributed

ACTs procured The number of ACT treatment courses procured by the public and private sector2 has increased greatly, from 11.2 million in 2005 to 76 million in 2006 and to 331 million in 2012 (Figure 6.6). Artemether-lumefantrine (AL) continued to account for the largest volume of ACTs procured by the public and private sector (77%) in 2012, followed by artesunate + amodiaquine, which accounted for 22% of ACTs procured. The proportion of xeddose combination ACTs (with the two medicines combined in the same tablet), which are preferred because of improved patient adherence to the recommended regimen, has been increasing, and in 2012 it accounted for 99% of all ACT sales. In 2012, a similar proportion of AL (31%) was procured for young children weighing <15 kg as for patients with a body weight of >35 kg (32%), followed by doses for children weighing 1524 kg (28%), and patients with a body weight of 2534 kg (9%). Compared
2. Data provided by 8 manufacturers eligible for procurement from WHO/ UNICEF and AMFm reports. Routine ACT public sector deliveries monitored 20052012; AMFm-facilitated public and private sector deliveries through AMFm monitored 20102012, in 2010 by AMFm reports and in 20112012 by reports of manufacturers ACT deliveries through non-AMFm private sector channels are not monitored, but are estimated to be a small fraction (about 510%) compared to public sector deliveries.

6.3 Treatment of malaria

6.3.1 Policy adoption
The adoption of policies for the treatment of malaria is summarized by WHO region in Table 6.2, and by country in Annexes 2A and 2B. In 2012, ACTs had been adopted as national policy

Box 6.1 Use of RDTs for diagnosis of P. vivax

Combination RDTs that can detect more than one Plasmodium species are increasingly deployed; also, the quality of RDTs deployed, including those that can detect P. vivax, has improved (see Section 6.2.2). In 2012, among 42 countries that reported the types of RDTs deployed in public health facilities, 15 reported deploying both P. falciparum-specic RDTs and P. vivax-specic RDTs (12 countries used a P. vivax-specic RDT, and 3 used a pan-specic combination test); 16 countries deployed a test specic for P. falciparum; and 11 countries deployed both a P.falciparum-specic test and a non-species specic combination test. Among 13 countries that provided information on cases diagnosed by RDT or microscopy by species, the proportion of P. vivax cases diagnosed by RDT ranged from <1% to 81%. In most countries, the proportion of P. vivax cases diagnosed by RDT (rather than by microscopy) was similar to the proportion of P. falciparum cases diagnosed by RDT.
Figure Box 6.1 Proportion of P. falciparum and P. vivax cases diagnosed by RDT
100%
Proportion P. vivax cases diagnosed by RDT

80% 60% 40% 20% 0%

0% 20% 40% 60% 80%

y=x

100

Proportion P. falciparum cases diagnosed by RDT

RDT, rapid diagnostic test Source: National Malaria Control Programme reports

40 | WORLD MALARIA REPORT 2013

Table 6.2 Adoption of policies for malaria treatment by WHO region, 2012
Policy AFR AMR EMR EUR SEAR WPR Total

ACT for treatment of of P. falciparum Pre-referral treatment with quinine/artemether IM/artesunate suppositories Single dose primaquine (0.25mg base/kg) as gametocidal for P. falciparum Primaquine for radical treatment of P. vivax cases Directly observed treatment with primaquine G6PD test is recommended before treatment with primaquine Number of countries/areas with ongoing malaria transmission Number of P. falciparum endemic countries/areas Number of P. vivax endemic countries/areas Number of countries/areas endemic for both P. falciparum and P. vivax

42 33 4 7 3 3 44 43 7 6

9 4 15 21 12 21 18 20 17

9 6 3 5 1 3 9 9 6 6

1 2 3 3 5 0 5 0

9 6 6 9 3 1 10 9 10 9

9 3 2 7 4 6 10 9 10 9

79 52 32 52 26 13 99 88 58 47

ACT, artemisinin-based combination therapy; AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; G6PD, Glucose-6-phosphate dehydrogenase; RDT, rapid diagnostic test; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National malaria control programme reports Figure 6.6 ACT deliveries to the public sector and private sector, 20052012
350 Treatment courses (millions) 300 250 200 150 100 50 0
2005 2006 2007 2008 2009 2010 2011 2012

Figure 6.9 Number of ACT treatment courses distributed by NMCPs, by WHO region, 20052012
160 140 120 100 80 60 40 20 0 AFR AMR EMR EUR SEAR WPR

AL AS-AQ (FDC) AS+AQ (Co-B) AS+MQ AS+MP Treatment courses (millions)

2005

2006

2007

2008

2009

2010

2011

2012

Figure 6.7 Artemether-lumefantrine deliveries to the public sector and private sector, by weight-based treatment course, 20062012
300 Treatment courses (millions) 250 200 150 100 50 0
2006 2007 2008 2009 2010 2011 2012

ACT, artemisinin-based combination therapy; AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National malaria control programme reports

AL 35+ kg AL 2534 kg AL 1524 kg AL 515 kg

with the previous year, the amount of AL that was procured in 2012 for young children weighing <15 kg increased by 35%, and the amount for children 1524 kg by 82%, whereas the amount for those weighing >35 kg stayed the same, and the amount for those weighing 2534 kg decreased by 20% (Figure 6.7). The increase in ACTs procured in 2012 was from increased procurements for routine public sector deliveries, which increased by about 50% from 2011 to 2012. Drugs procured for the public and private sector through the Aordable Medicines Facility-malaria (AMFm) initiative which is now in a transitional phase towards eventual integration into the routine grant-making processes of the Global Fund to Fight Aids, Tuberculosis and Malaria (Global Fund) decreased slightly from 156 million treatment courses in 2012 compared with 150 million in 2011 (Figure 6.8). ACTs distributed by national programmes The number of ACTs distributed by NMCPs provides information on where ACTs procured from manufacturers are deployed through the public sector. The number of ACTs distributed by NMCPs increased between 2009 and 2012 (Figure 6.9); however, due to incomplete reporting by countries and possible delays between delivery of ACTs by manufacturers and distribution by NMCPs, the totals do not match those delivered by manufacturers. The majority of ACTs distributed by NMCPs are in Africa, which accounted for 134 of 147 million treatments reportedly distributed by NMCPs worldwide in 2012.
WORLD MALARIA REPORT 2013 | 41

Figure 6.8 ACT deliveries, by health sector and AMFm contribution, 20052012
350 Treatment courses (millions) 300 250 200 150 100 50 0
2005 2006 2007 2008 2009 2010 2011 2012

AMFm private sector AMFm public sector Public sector

ACT, artemisinin-based combination therapy; AL, artemether-lumefantrine, AMFm, Aordable Medicine Facility malaria; AQ, amodiaquine, AS, artesunate; Co-B, co=blistered pack; FDC, xed-dose combination; MQ, meoquine; SP, sulfadoxine-pyrimethamine Source (Figures 6.6, 6.7, 6.8): Data provided by 8 manufacturers eligible for procurement from WHO/UNICEF and AMFm reports Routine ACT public sector deliveries monitored 20052012; AMFm-facilitated public and private sector deliveries through AMFm monitored 20102012, in 2010 by AMFm reports and in 20112012 by reports of manufacturers ACT deliveries through non-AMFm private sector channels are not monitored, but are estimated to be a small fraction (about 510%) compared to public sector deliveries

6.3.3 Use of appropriate antimalarial medicines to treat patients with malaria in the public sector and private sector, and in the community
It has been dicult to track the extent to which patients with conrmed malaria (by RDT or microscopy) receive appropriate antimalarial medicines. Common sources for this information include household surveys and routine information systems. An increasing number of household surveys have included questions on both diagnostic testing and receipt of antimalarial medications. However, the validity of survey responses given to questions about test results and treatments is uncertain. A recent comparison of responses given in a household survey, with observed testing and treatment provided at health facilities, showed that sensitivity and specicity of caregivers recall of diagnostic and treatment information was moderate and greater for receipt of treatment than
Figure 6.10 Proportion of estimated presumed and conrmed P. falciparum cases at public facilities potentially treated with distributed ACTs, by WHO region, 20052012
World 100% 80% Proportion 60% 40% 20% 0%

for receipt or results of a diagnostic test (8). Routine information systems usually include data on diagnostic conrmation, but they rarely track treatments given to patients diagnosed with malaria. If they do, the receipt of treatment cannot easily be linked to the diagnostic test result. The development of routine systems that track febrile patients, testing, results and treatments given would enable better tracking of the use of antimalarials; however, such systems are as yet uncommon. Use of appropriate antimalarial medicines, national programme reports On the basis of the available data from national programmes on the number of ACT treatments distributed and the number of estimated presumed (cases treated without being tested) and conrmed P. falciparum cases in the public sector, it is possible to calculate the proportion of malaria cases from public facilities that could potentially be treated with ACTs. The proportion of presumed and conrmed P. falciparum cases potentially treated by distributed ACTs has varied over time (Figure 6.10). The trend in the African Region, which accounts for the over 90% of the estimated ACT treatment need, has risen steadily since 2005, in line with the increasing ACT deliveries by manufacturers and distributions by NMCPs; in 2012 it reached 60%. Trends in other regions are heavily inuenced by inconsistent reporting by certain countries. An increasing number of countries have provided information on ACT distributions over time. Therefore, proportions of presumed and conrmed P. falciparum cases potentially treated with ACTs have been less subject to reporting bias in more recent years, and are more likely to reect true access to ACTs. Data from national programmes regarding treatment of P. vivax cases has been more limited than that for treatment of P. falciparum, although some insights can be gained by assessing the use of primaquine treatments (Box 6.2)

AFR

AMR

EMR

EUR

SEAR

WPR*

2005

2006

2007

2008

2009

2010

2011

2012

*WPR does not include Papua New Guinea due to incomplete data ACT, artemisinin-based combination therapy; AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; RDT, rapid diagnostic test; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme reports

Box 6.2 Treatment of P. vivax with primaquine

Primaquine is currently the only drug available to treat the liver stage (hypnozoite) of P. vivax infection (i.e. radical treatment). Fifty-two countries reported adopting a policy of radical treatment with primaquine, and 26 of these countries have adopted a policy of directly observed therapy with primaquine; 13 countries require testing for G6PD activity before treatment with primaquine (see Section 6.3.1). Information on the extent to which patients with cases of P. vivax malaria are given radical treatment with primaquine has been lacking. For the World Malaria Report 2013, country programmes were asked to provide information on the number of treatment courses of primaquine distributed for use in public health facilities. The number of primaquine treatment courses reported by 24 national programmes was compared to the estimated number of P. vivax cases in public facilities for each country, similar to the way in which the proportion of P. falciparum cases potentially treated was calculated. The proportion of P. vivax cases potentially treated with primaquine varied widely (Figure Box 6.2), and appeared to be correlated with the proportion of malaria cases due to P. vivax in each country. Among countries that recommend testing for G6PD activity before primaquine treatment, only
42 | WORLD MALARIA REPORT 2013

Algeria and Saudi Arabia reported distributing any primaquine treatment. Overall, about 10% of all patients with P. vivax in the 24 countries reporting on primaquine treatment could be potentially treated with the primaquine doses distributed.
Figure Box 6.2 Proportion of estimated P. vivax cases potentially treated with primaquine treatments distributed, by proportion of malaria cases due to P. vivax, 2012
100%
Proportion P. vivax cases potentially treated

80% 60% 40% 20% 0%

0% 20% 40%

R2=0,871

60%

80%

100%

Proportion malaria cases due to P. vivax

Source: National Malaria Control Programme reports

Use of appropriate antimalarial medicines, household surveys From household survey data it is possible to examine the proportion of febrile children receiving antimalarial treatments who were given an ACT in the public sector and the private sector.

In nine countries, at least two surveys that included information on the type of malaria treatment and the place of care were conducted during 20062012, (Figure 6.11). In all but 1 of these 22 surveys, a higher proportion of children treated for malaria in the public sector received ACTs than those treated in the private

Figure 6.11 Proportion of ACTs among antimalarial treatments given to febrile children, by health sector, among countries with at least two surveys, 20062012
100% 80% Proportion ACTs 60% 40% 20% 0% Public sector Private sector

2006 2011 Angola

2007 2009 2011 Liberia

2009 2011 Madagascar

2010 2012 Malawi

2008 2010 Nigeria

2008 2010 Rwanda

2006 2009 2011 2008 2010 2012 Senegal United Republic of Tanzania

2006 2009 2011 Uganda

Public sector includes government and non-prot facilities, and community health workers; Private sector includes private clinics and providers, pharmacies, shops and traditional providers. ACT, artemisinin-based combination therapy Source: Household surveys

Box 6.3 Estimating appropriate treatment of malaria

Although household surveys only record whether a child has had a fever, rather than conrmed malaria, results of RDTs administered by the surveyors at the time of a survey provide insight into the proportion of fevers in the previous 2 weeks that were associated with malaria parasites (because antigens detected by RDTs, can persist even after appropriate treatment). Therefore, the proportion of children who had a positive RDT and a fever in the 2 weeks before the survey, represents an approximate two week period prevalence of malaria parasite infection or conrmed malaria.1 If this is combined with information on receipt of ACT reported during the survey, it is possible to estimate the proportion of children with conrmed malaria that received treatment with ACT. Dening conrmed malaria as a report of fever within the two weeks before the survey and a positive RDT at the time of survey, the proportion of all children with conrmed malaria that received treatment with ACT has been low: below 50% in 42 surveys conducted between 2006 and 2012 (Figure Box 6.3a). The proportion of conrmed malaria treated with ACT appears to be higher in households surveys with a greater proportion of febrile children brought for care. The proportion of children with conrmed malaria receiving ACT was higher in most surveys conducted in 20102012 than in those conducted in 20062009. Across 26 surveys during 20102012, the mean proportion of children with conrmed malaria receiving ACTs was 16 % (range 1%-42%). A low proportion of children who are not brought for care receive ACT, whether they have conrmed malaria or not (Figure Box 6.3b). In most surveys, a higher proportion of children with conrmed malaria who were brought for care at public or private health facilities received ACT than those without conrmed malaria, a nding that may reect the availability of diagnostic testing at health facilities . However, the proportion of children without conrmed malaria that receive ACTs is
1. For surveys in which RDT is not performed (most Demographic and Health Surveys and Multiple Indicator Cluster Surveys) the likelihood of a respondent having a positive RDT can be modeled from the parasite prevalence in the area and individual and household characteristics.

still high, suggesting either that diagnostic testing is not being performed or that the results are not being used to guide malaria treatment nearly to the extent that they could be. Increased access to care for fever, as well as appropriate diagnostic testing and therapeutic management at all places of care, is needed to ensure that all patients with malaria receive prompt and eective treatment.
Figure Box 6.3a The proportion of febrile children with positive RDT that received ACTs and the proportion of febrile children brought for care, by older and more recent surveys, 2006--2012 20062009 20102012
Proportion of febrile children with positive RDT that receive ACTs

100% 80% 60% 40% 20% 0%

0%

20%

40%

60%

80%

100%

Proportion of febrile children brought for care

Proportion of febrile children with negative RDT that received ACTs

Figure Box 6.3b The proportion of febrile children with positive RDT that received ACTs and the proportion of febrile children with negative RDT that received ACTs, 2006--2012 Public sector Private sector Not brought for care
100% 80% 60% 40% 20% 0%
0% 20% 40% 60% 80% 100%

y=x

Proportion of febrile children with positive RDT that received ACTs

ACT, artemisinin-based combination therapy; RDT, rapid diagnostic test Source: Households surveys

WORLD MALARIA REPORT 2013 | 43

sector. In nearly all follow-up surveys, the proportion of febrile children receiving antimalarial treatment who received an ACT had increased from the previous survey, in both the public and private sectors. In the most recent surveys for these countries, the median proportion receiving an ACT among all children who received antimalarial treatment was 68%. This is a substantial level of ACT treatment among those treated, although it does not include those who did not seek care and thus received no treatment. Also, it is not possible to determine from these data what proportion of the children had conrmed malaria. The proportion of all patients with malaria who are appropriately diagnosed and treated for malaria is likely to be much lower (see Box 6.3). Ensuring that all patients with malaria are appropriately diagnosed and treated involves increasing access to diagnosis and treatment, and providing appropriate testing and treatment to those who do seek care.

Figure 6.12 Ratio of RDT and microscopy performed to ACTs distributed, African Region, 2006-2012

More tests performed than ACTs administered

Ratio 1

Fewer tests performed than ACTs administered

2006

2007

2008

2009

2010

2011

2012

ACT, artemisinin-based combination therapy; RDT, rapid diagnostic test Source: National malaria control programme reports

Figure 6.13 Number of countries allowing marketing of oral artemisinin-based monotherapies by WHO region, 20082013
2008 2009 2010 2011 2012 2013

60 50
Number of countries

40 30 20 10 0 World AFR AMR EMR EUR SEAR WPR

6.3.4 Scaling up diagnostics and reducing treatment needs

Although many patients with suspected malaria still do not receive a parasitological test, the recent expansion of malaria diagnostic testing as evidenced by the increase in RDTs sales, RDTs distributed by country programmes and microscopy performed has resulted in an increase in the proportion of suspected malaria cases tested at public facilities. In the African Region during 20062012, the total number of tests (microscopy + RDTs) conducted in the public sector has increased compared with the number of ACTs distributed by NMCPs during the year (Figure 6.12). In 2012, nearly as many patients were tested as received an ACT. This is an encouraging trend; however, considering that test positivity rates in most areas in Africa are less than 50%, if diagnostic testing is fully implemented, the ratio of diagnostic tests to ACTs should be 2. The data indicate that, although substantial progress has been made, the scale-up of diagnostic testing through RDTs and microscopy remains incomplete in the public sector, and to an even greater extent in the private sector. Expanding diagnostic testing, particularly through the scaleup of RDTs, can signicantly reduce the need for ACTs and can thus reduce expenditures on antimalarial drugs (9). Overall cost-savings will depend on the intensity of malaria transmission and other factors; however, RDTs are costeective compared to presumptive treatment, in part due to improved patient outcomes for non-malarial febrile illness (10). Promotion of testing starts at the level of programme planning, budgeting and procurement. Country programmes and their supporting donors should aim to provide sucient microscopy services and to procure an appropriate number of RDTs and ACTs (based on local data), according to procurement guidance described in WHO documents. If the projected number of ACTs required exceeds the estimated number of RDTs and microscopy required, the calculations should be carefully reviewed, because the ratio of diagnostic tests to ACTs procured for the public sector should exceed 2 in nearly every malaria-endemic setting.
44 | WORLD MALARIA REPORT 2013

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: http://www.who.int/malaria/monotherapy_NDRAs.pdf

Figure 6.14 Status of therapeutic ecacy monitoring in countries with ongoing malaria transmission, 2008-2012
Studies not possible* No TES conducted TES conducted Number of endemic countries

100 80 40 60 20 0 31
31

24

24

28 24

32 19

28 22

44

44

47

48

49

20082009

20112012

*TES studies are impractical in countries with low malaria transmission or transmission of P. vivax only TES, therapeutic ecacy study Source: WHO Global Malaria Program database on antimalarial therapeutic ecacy monitoring by country, November, 2013

6.4 Antimalarial drug resistance

6.4.1 Policy adoption: withdrawal of oral artemisininbased monotherapy medicines
The use of oral artemisinin-based monotherapies threatens the long-term usefulness of ACTs by fostering the emergence or spread of resistance to artemisinin. To contain this risk and to ensure high cure rates for P. falciparum malaria, WHO has long recommended the withdrawal of oral artemisinin-based monotherapies from the market, and their replacement by ACTs, as endorsed by the World Health Assembly in 2007.3 WHO also calls
3. The full text of the World Health Assembly resolution can be found at http://apps.who.int/gb/ebwha/pdf_les/WHA60/A60_R18-en.pdf.

upon manufacturers to cease the marketing of oral artemisininbased monotherapies. To track adherence to this recommendation, WHO compiles data on the marketing of oral artemisinin-based monotherapies by manufacturers and on the regulatory action taken by malaria-endemic countries; these data are posted on the Internet.4 When the World Health Assembly resolution was adopted, 55 countries worldwide, including 30 in Africa, allowed the marketing of oral artemisinin-based monotherapies. As of October, 2013, only 9 countries still allowed the marketing of these products (Figure 6.13): Angola, Cabo Verde, Equatorial Guinea, Gambia, Sao Tome and Principe, Swaziland (in the African Region); Colombia (in the Region of the Americas); Somalia (in the Eastern Mediterranean Region); and Timor Leste (in the Western Pacic Region). As of August 2013, a total of 30 pharmaceutical companies, most located in India, continued to market oral artemisinin monotherapies. Although regulation of pharmaceutical markets in many malaria-endemic countries presents a challenge, steady progress has been made in phasing out oral artemisininbased monotherapy. Greater collaboration and involvement of national regulatory authorities with NMCPs is required to ensure complete withdrawal of oral artemisinin-based monotherapies from all countries.

Figure 6.15 Prioritized areas for artemisinin resistance containment activities, Greater Mekong subregion, 2013

6.4.2 Drug ecacy monitoring

Status of drug ecacy monitoring Therapeutic ecacy studies remain the gold standard for guiding drug policy; the standard WHO protocol was updated in 2009 (11). In the WHO Global Database on Antimalarial Drug Ecacy, WHO compiles the results of ecacy tests conducted by national programmes and research institutes. The database currently contains over 4000 studies carried out between 1996 and 2012, and forms the basis of the Global report on antimalarial drug ecacy and drug resistance: 20002010 (12). Experience with previous antimalarial treatments shows that signicant levels of resistance can develop within a short time; therefore, WHO recommends that the ecacy of rst- and second-line antimalarial treatments should be monitored at least once every 2 years. In 20112012, studies of rst- or second-line antimalarial treatments were completed in 48 of 67 (72%) countries where P. falciparum ecacy studies were possible,5 an increase from 41% of countries that conducted studies during 20082009 (Figure 6.14). Importantly, 19 countries did not conduct studies during 20112012, and were therefore not in compliance with the WHO recommendation on antimalarial drug ecacy monitoring.
Tier I are areas where there is credible evidence of artemisinin resistance; tier II are areas with signicant inows of people from Tier I areas, including those immediately bordering Tier I; Tier III are areas with no evidence of artemisinin resistance and limited contact with Tier I areas Source: Global Malaria Programme, WHO, November, 2013

Status of P. falciparum resistance to artemisinin6 Routine monitoring of the therapeutic ecacy of ACTs is essential for timely changes to treatment policy, and it can help to detect early changes in P. falciparum sensitivity to artemisinins. WHO currently recommends changing antimalarial treatment policy when the treatment failure rate in a 28 or 42 day follow-up study (depending on the medicine) exceeds 10%. The proportion of patients who are parasitaemic on day 3 of treatment is currently the best widely available indicator used in routine monitoring to measure P. falciparum sensitivity to artemisinins. The working denition of suspected resistance to artemisinins is dened as an increase in parasite clearance time, as evidenced by 10% or more cases with parasites detectable on day 3 of treatment with an ACT; conrmed resistance is dened as treatment failure after treatment with an oral artemisinin-based monotherapy (administered under special study conditions) with adequate antimalarial blood concentration, as evidenced by the persistence of parasites for 7 days, or the presence of parasites on day 3, and recrudescence within 28 or 42 days (depending on the drug). In recent years, P. falciparum resistance to artemisinins has been detected in four countries in the Greater Mekong subre6. Status of artemisinin resistance as of April, 2012: http://www.who.int/ malaria/diagnosis_treatment/resistance/updateartemsininresistanceapr2012/en/index.html WORLD MALARIA REPORT 2013 | 45

4. Information is available via the following links: Manufacturing companies: http://www.who.int/malaria/monotherapy_manufacturers.pdf; National Regulatory Authorities: http://www.who.int/malaria/monotherapy_ NDRAs.pdf 5. In certain countries (32 in 2012), ecacy studies are impractical because of low malaria incidence, or because the countries are endemic for P. vivax only.

gion: Cambodia, Myanmar, Thailand and Viet Nam. Despite these changes in parasite sensitivity to artemisinins, ACTs have generally remained clinically and parasitologically ecacious so long as the partner drug remains ecacious. In Pailin province, Cambodia, resistance to artemisinin and to several partner drugs in commonly used ACTs has been conrmed. Resistance to piperaquine is under investigation after a study in 2010 found 27% treatment failure with dihydroartemisinin-piperaquine. Due to the high failure rate of ACTs in Pailin, a consensus meeting held in November 2011 in Cambodia recommended the use of atovaquone-proguanil delivered as directly observed therapy for Pailin province; stringent follow-up of all treated patients was also recommended to detect any emergence of atovoquone resistance. Treatment options for this area continue to be reviewed. P. falciparum resistance to artemisinins has not been documented outside of the Greater Mekong subregion. In South America, therapeutic ecacy studies conducted in a few countries during 20122013 reported an increased proportion of day-3 positive patients after treatment with AL. Review of the data from these studies by the Drug Resistance and Containment Technical Expert Group (DRC-TEG) of the Malaria Policy Advisory Committee (MPAC) concluded that there was no denitive evidence of artemisinin resistance. The DRC-TEG recommended that detailed conrmatory studies be conducted in Suriname, Guyana and neighbouring countries, and that malaria control measures be strengthened in these countries. To date, there have been no reports of delayed parasite clearance during routine therapeutic ecacy studies conducted in Africa. Chloroquine resistance in P. vivax malaria Chloroquine remains the currently recommended drug for the treatment of P. vivax in areas where the drug is still eective. Treatment failure on or before day 28 , or prophylactic failures (or both) have been observed in 23 countries: Afghanistan, Bolivia, Brazil, Cambodia, China, Colombia, Guyana, Ethiopia, India, Indonesia, Madagascar, Malaysia (Borneo), Myanmar, Pakistan, Papua New Guinea, Peru, the Republic of Korea, Solomon Islands, Thailand, Turkey, Sri Lanka, Vanuatu and Viet Nam. However, conrmation of true chloroquine resistance requires additional drug concentration studies; hence, it is not entirely clear to what extent chloroquine-resistant P. vivax has spread. Among the countries with P. vivax treatment or prophylactic failure listed above, at least one case of chloroquineresistant vivax malaria has been conrmed in 10 countries: Bolivia, Brazil, Ethiopia, Indonesia, Malaysia (Borneo), Myanmar, Solomon Islands, Thailand, Papua New Guinea and Peru. ACTs are now recommended for the treatment of chloroquine-resistant P. vivax, particularly where ACTs have been adopted as the rst-line treatment for P. falciparum. Containment of artemisinin resistance In follow-up to the Global Plan for Artemisinin Resistance Containment (GPARC) (13), which was launched in 2012, WHO released the Emergency response to artemisinin resistance in the Greater Mekong subregion: A regional framework for action 20132015 (ERAR) in 2013 (14). The emergency plan provides further guidance for eld implementation of the containment eorts outlined in the GPARC. The framework identies four
46 | WORLD MALARIA REPORT 2013

priority areas where action is needed in the coming years to contain artemisinin resistance and move towards elimination of malaria: reaching all risk groups with full coverage of quality interventions in priority areas; achieving tighter coordination and management of eld operations; obtaining better information for artemisinin resistance containment; and strengthening regional oversight and support. As described in the GPARC, the ERAR denes geographic priority areas for implementation of containment eorts. Tier I are areas where there is credible evidence of artemisinin resistance for which intensied and accelerated malaria control towards universal coverage is recommended; Tier II are areas with signicant inows of people from Tier I areas, including those immediately bordering Tier I, where intensied and accelerated control is recommended; Tier III are areas with no evidence of artemisinin resistance and limited contact with Tier I areas for which good malaria control is emphasized. The boundaries of these geographical priority areas have recently been updated (Figure 6.15), and they will be periodically reviewed and updated by the DRC-TEG and the MPAC in consultation with countries aected, as ecacy study results become available.

6.5 Conclusions
Implementation of parasitological testing
There have been signicant increases in the availability and use of parasitological testing in recent years, particularly in the African Region, where the proportion of reported suspected cases receiving a parasitological test in the public sector increased dramatically from 37% in 2010 to 61% in 2012. Most of the increase is attributable to an increase in the use of RDTs, although reported microscopy increased substantially in the African region as well. The limited information available indicates that testing in the private sector is less than the public sector, and overall testing rates are well below the target of testing all suspected malaria cases. Further funding and technical support are required to help countries to achieve universal diagnostic testing of suspected malaria in the public and private sector, and in the community. Promotion of malaria diagnostic testing needs to begin during planning, budgeting and procurement. Considering that in most malaria-endemic areas, malaria diagnosis will be conrmed in less than half of patients tested, programmes should aim to obtain at least as many diagnostic tests as ACT treatment courses until such time as surveillance and test consumption data allow for more precise procurement estimation.

Access to treatment
Information from manufacturers and from country programmes indicates that the number of ACTs procured has increased dramatically since 2005. It is dicult to track the extent to which patients with conrmed malaria (by RDT or microscopy) receive antimalarial medicines, because diagnostic test results are not usually linked to the treatment given to patients, in either household surveys or routine information systems. A limited number of recent household surveys suggest that febrile patients attending public health facilities who are treated for malaria are more likely to receive an ACT than those attending private

facilities; in countries surveyed most recently, the proportion has increased in both public and private sectors. Using RDT result as a proxy for conrmed malaria, the proportion of patients with conrmed malaria who receive treatment with ACT is low. This is due to a substantial proportion of patients who do not seek care as well as under-treatment at facilities. At the same time, given low rates of testing among patients treated for malaria, a substantial proportion of those who do receive ACTs probably do not have malaria. Consequently, both undertreatment and overtreatment with ACT continues. The development of routine systems that track febrile patients, diagnostic testing, test results, and treatments administered would enable better tracking of antimalarial use. Given that routine system development may take time, national programmes may consider other sources of testing and treatment information, such as health facility-based surveys.

References
1. Guidelines for the treatment of malaria, Second edition. Geneva, World Health Organization, 2010 (http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf, accessed 15 October 2013). 2. World Health Organization (WHO). Universal access to Malaria diagnostic testing. Geneva, WHO, 2011 (http://whqlibdoc.who.int/publications/2011/9789241502092_eng.pdf, accessed 24 November 2013). 3. World Health Organization (WHO). Good procurement practices for artemisinin-based antimalarial. Geneva, WHO, 2010 (http:// apps.who.int/medicinedocs/documents/s17072e/s17072e.pdf, accessed 24 November 2013). 4. World Malaria Report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/world_malaria_ report_2012/en/index.html, accessed 15 October 2013). 5. DAcremont V, Lengeler C, Genton B. Reduction in the proportion of fevers associated with Plasmodium falciparum parasitaemia in Africa: a systematic review. Malar J, 2010, 9:240 (http://www.ncbi. nlm.nih.gov/pubmed/20727214, accessed 24 November 2013). 6. Malaria rapid diagnostic test performance. Geneva, World Health Organization (WHO), 2012 (http://apps.who.int/iris/bits tream/10665/77748/1/9789241504720_eng.pdf, accessed 24 November 2013). 7. Disease surveillance for malaria control. Geneva, World Health Organization, 2012 (http://apps.who.int/iris/bitstream/10665/ 44851/1/9789241503341_eng.pdf, accessed 24 November 2013). 8. Eisele TP, Silumbe K, Yukich J, Hamainza B, Keating J, Bennett A et al. Measuring coverage in MNCH: accuracy of measuring diagnosis and treatment of childhood malaria from household surveys in Zambia. PLoS Med, 2013, 10(5):e1001417 (http://www.ncbi.nlm.nih. gov/pubmed/23667337, accessed 24 November 2013). 9. Thiam S, Thior M, Faye B, Ndiop M, Diouf ML, Diouf MB et al. Major reduction in anti-malarial drug consumption in Senegal after nationwide introduction of malaria rapid diagnostic tests. PLoS ONE, 2011, 6(4):e18419 (http://www.ncbi.nlm.nih.gov/pubmed/21494674, accessed 24 November 2013). 10. Shillcutt S, Morel C, Goodman C, Coleman P, Bell D, Whitty CJ et al. Cost-eectiveness of malaria diagnostic methods in subSaharan Africa in an era of combination therapy. Bull World Health Organ, 2008, 86(2):101-110 (http://www.ncbi.nlm.nih.gov/ pubmed/18297164, accessed 24 November 2013). 11. Methods for surveillance of antimalarial drug ecacy. Geneva, World Health Organization, 2009 (http://whqlibdoc.who.int/publications/2009/9789241597531_eng.pdf, accessed 24 November 2013). 12. Global report on antimalarial drug ecacy and drug resistance: 2000 2010. Geneva, World Health Organization, 2010 (http://whqlibdoc. who.int/publications/2010/9789241500470_eng.pdf, accessed 24 November 2013). 13. Global plan for artemisinin resistance containment. Geneva, World Health Organization, 2011 (http://www.who.int/malaria/publications/atoz/9789241500838/en/, accessed 15 October 2013). 14. Emergency response to artemisinin resistance in the Greater Mekong subregion. Regional Framework for Action 20132015. Geneva, World Health Organization, 2013 (http://www.who.int/malaria/publications/atoz/9789241505321/en/index.html, accessed 20 October 2013).

Combating drug resistance

The recent spread of resistance to antimalarial drugs has led to an intensication of eorts to prohibit the marketing of oral artemisinin-based monotherapies and to expand antimalarial drug ecacy monitoring. In the past year, seven more countries have withdrawn marketing authorization for oral artemisinin-based monotherapies, but nine countries still allow such marketing. The number of countries conducting therapeutic ecacy studies for antimalarial drugs has increased, particularly in the African Region, where the reliance on ACTs is high. Despite the observed changes in parasite sensitivity to artemisinins, ACTs remain ecacious in curing patients, provided that the partner drug is still ecacious. The ERAR was released in 2013 to guide countries in the region in implementing containment eorts.

WORLD MALARIA REPORT 2013 | 47

48 | WORLD MALARIA REPORT 2013

CHAPTER 7

Malaria surveillance, monitoring and evaluation

This chapter examines the extent to which data are available for reporting on key WHO and Roll Back Malaria (RBM) indicators from: (i) routine information systems, and (ii) household surveys.

7.2.1 Malaria case incidence

In 2012, WHO estimated that there were 207 million malaria cases worldwide (Chapter 8, Section 8.3), and received reports of 30 million conrmed cases from endemic countries, representing a case detection rate of 14% globally (an increase from 3% in 2000 and 11% in 2010). Much of the increase in the case detection rate is due to increased diagnostic testing in the WHO African Region, through the use of rapid diagnostic tests (RDTs) (see Chapter 6, Section 6.2). Case detection rates are lower in countries with higher estimated numbers of cases (Figure 7.1); therefore, by this criterion, surveillance systems are weakest where the malaria burden is highest. Surveillance systems do not need to detect all cases in order to assess trends in malaria incidence; however, case detection eorts do need to be reasonably uniform over time. Every year, WHO assesses whether or not case reporting is suciently consistent from year to year to make it possible to draw conclusions about trends in disease incidence. This involves examining the number of diagnostic tests carried out, and the proportion of monthly health-facility reports received; monitoring trends in total patient attendances and proportionate morbidity (e.g. test positivity rate and percentage of admissions due to malaria); and examining the consistency of trends between dierent malaria indicators (cases, admissions and deaths). In 2012, in 62 countries of 103 that had been endemic for malaria in 2000, reporting was considered to be suciently consistent to make a reliable judgement about malaria trends for 20002012 (Chapter 8; Table 8.1). Although these countries comprise the majority of malariaendemic countries, they account for just 15% of the estimated total number of cases worldwide. In the remaining 41 countries, in which most malaria cases (85%) are present, it is not possible
Figure 7.1 Proportion of malaria cases captured by surveillance systems, in relation to total estimated number of cases, 2012, and whether trends over time can be assessed Unable to assess trends
100% Proportion of cases reported, 2012 80% 60% 40% 20% 0% 1 100 10 000 1 000 000 100 000 000

7.1 Introduction
WHO, together with other RBM partners, recommends that a core set of indicators be used for malaria surveillance, monitoring and evaluation (see Chapter 2, Table 2.2) (1). The World Malaria Report aims to report annually on relevant indicators,1 for all countries with ongoing malaria transmission. The key indicators are derived from two main data sources: routine health information systems and household surveys. This chapter reviews global trends on availability of these indicators.

7.2 Indicators derived from routine information systems

Of the 15 key indicators in Table 2.2 (Chapter 2), 7 can be derived from routine information systems: the proportion of suspected cases receiving a parasitological test and the proportion of conrmed cases that receive rst-line antimalarial according to national policy are discussed in Chapter 6; the proportion of the population protected by indoor residual spraying (IRS) is summarized in Chapter 4; the number of new countries in which malaria has been eliminated is reported in Chapter 8; the percentage of districts reporting monthly numbers of suspected malaria cases, number of cases receiving a diagnostic test and number of conrmed malaria cases is not currently available at global level, but some insight can be obtained from reported data on conrmed cases; and conrmed malaria cases per 1000 persons per year (malaria case incidence) and inpatient malaria deaths per 100 000 persons per year (malaria mortality rate) are the focus of this section. The ability of routine information systems to provide reliable information on malaria case incidence and mortality rate is inuenced by several factors: (i) the extent to which malaria patients seek treatment; (ii) whether or not patients use and die in health facilities covered by a countrys surveillance system; (iii) the proportion of patients who receive a reliable diagnostic test; and (iv) the completeness of recording and reporting (see Chapter 7 of the World malaria report 2012 (2).
1. Some indicators are only relevant for certain geographical regions or programme phases.

Able to assess trends

Source: National malaria control programme data, WHO estimates

Estimated number of malaria cases, 2012

WORLD MALARIA REPORT 2013 | 49

Proportion of all deaths reported from health faciltiess, 200820012

to assess malaria trends from reported data on case incidence submitted to WHO, because of incompleteness or inconsistency of reporting over time. Thus, measured by this criterion, information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.

Figure 7.2 Proportion of all deaths cases captured from health-facility reports in relation to total estimated number of deaths, 2012
100% 80% 60% 40% 20% 0% 1 100 10 000 1 000 000 100 000 000 Estimated number of malaria deaths, 2012
Source: National malaria control programme data, Vital registration database, WHO estimates

7.2.2 Malaria mortality rates

It is not possible to examine the proportion of malaria deaths that are reported in relation to total estimated malaria deaths, because not all malaria deaths are conrmed by a parasitological test. However, it is possible to examine the total number of deaths reported from all causes, and compare this to the number of all deaths expected to occur in a country, as derived from life tables (3). Such a comparison can give some insight into the extent of underreporting of malaria deaths. In 2012, only 45 malaia-endemic countries reported on healthfacility deaths from all causes as part of reporting for the World Malaria Report 2013. The countries that reported were mostly from highly endemic areas of Africa. Less highly endemic countries, particularly those outside Africa, were less likley to report on deaths from all causes. However, some data on the proportion of deaths registered in these countries are available from other sources (4). These data are correlated with the proportion of deaths reported for the World malaria report 2013. Hence, this source was used to infer the proportion of deaths occurring in health facilties for a further 21 countries. It is clear that a lower proportion of health-facilty deaths are reported in countries with the highest number of malaria deaths (Figure 7.2); again information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.

household survey, since IRS coverage may be better measured by routine information systems.

Questions on IPTp are only relevant in sub-Saharan Africa and in Papua New Guinea (see Chapter 5, Section 5.2). Questions on diagnostic testing and treatment are relevant in all settings, but may not be appropriate to include in a survey if the incidence of malaria is low, and the sample sizes required to obtain information on the rate of diagnostic testing and medicines taken would be too high. If the incidence of malaria in a population is 100 cases per 1000 persons at risk each year, then a sample of 5000 individuals will yield only 19 individuals with malaria over a 2-week period (the usual recall period for examining the treatment-seeking behaviour of fever cases), assuming that malaria occurs evenly over a year. For some countries with low incidence rates nationally, it may still be useful to conduct surveys subnationally. It may also be of interest to examine the extent of diagnostic testing for fever, even if the number of malaria cases is low. In some settings in which the number of cases expected to receive a diagnostic test in a sample is too low, it may still be appropriate to include questions on where patients seek treatment for fever, in order to better understand case detection rates of surveillance systems (see Section 7.1). The estimated incidence of malaria nationally exceeds 100 cases per 1000 population per year in 39 countries in sub-Saharan Africa, and has done so for at least 5 years between 2000 and 2012 in 9 countries outside sub-Saharan Africa (Afghanistan, Bangladesh, Cambodia, Guyana, Papua New Guinea, Solomon Islands, Suriname, Timor-Leste and Vanuatu). When parasite prevalence is low, then the sample sizes required to measure parasite prevalence with precision may also prove prohibitive. It is only appropriate to measure all-cause under-5 mortality rates as an indicator of the success of malaria control in situations where malaria accounts for a substantial proportion of deaths in children under 5 years of age. Malaria accounts for more than 10% of all under-5 deaths in 33 countries in subSaharan Africa, and (in at least some years since 2000) has accounted for more than 10% of deaths in 3 countries outside Africa (Papua New Guinea, Solomon Islands and Timor-Leste).

7.3 Indicators derived from household surveys

Household surveys can provide information on the following: coverage of preventive interventions insecticide-treated mosquito nets (ITNs), IRS and intermittent preventive treatment in pregnancy (IPTp) the coverage of IRS programmes is usually monitored through routinely collected data, rather than through a household survey, but a household survey can help to clarify the degree of overlap in the coverage of IRS and ITN programmes; where patients sought care for fever, whether or not they received a diagnostic test, the types of medicines taken and what proportion of antimalarial treatments were artemisininbased combination therapies (ACTs) or other rst-line treatments; and two indicators of health status: parasite prevalence and under-5 mortality rate. Household surveys are generally not appropriate for countries that are in the pre-elimination or elimination phase, in which malaria is highly focal; in such countries, malaria is best monitored through intensive surveillance. Moreover, not all indicators are relevant to all settings, owing to variation in the epidemiology of malaria and range of interventions implemented: If IRS is the sole means of vector control, then there may be little advantage to including vector control questions in a
50 | WORLD MALARIA REPORT 2013

Figure 7.3 Number of countries with household surveys measuring at least one malaria-specic indicator, 20002012
AFR 40 35 Number of countries with survey 30 25 20 15 10 5 0 2000
Source: Household surveys

AMR

EMR

EUR

SEAR

WPR

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region0

Figure 7.4 Number of household surveys conducted, 20002012

Survey Count, 2000-2013

0 1 2 3 4 5 6+

Source: Household surveys

Given the diversity of malaria epidemiology across the world, and the range of interventions adopted by national malaria control programmes (NMCPs), not all countries with ongoing transmission would be expected to conduct household surveys or measure all recommended indicators. The remainder of this chapter summarizes the availability of data on dierent indicators from nationally representative household surveys. It does not consider surveys whose sampling scheme is not representative of all malaria-endemic areas within a country, or surveys that employ non-random sampling schemes that prevent results from being generalized nationally.2 The number of countries with household surveys that enable at least one malaria-specic indicator to be calculated (i.e. not counting under-5 mortality rates) has uctuated between 2000 and 2013, with peaks in 2000, 2006, and 2010 (Figure 7.3). In total, 50 countries had at least one survey between 2011 and 2013, of which 34 were in the African Region (Figure 7.4). The most common type of survey has been the multiple indicator cluster survey (MICS) (115), followed by demographic and
2. If malaria is restricted to geographically limited areas within a country, and a survey is representative of these areas, then the survey can be considered to be nationally representative.

health surveys (DHS) (99) and malaria indicator surveys (MIS) (40). Both DHS and MICS aim to measure a range of maternal and child-health indicators, whereas MIS focus only on malariarelated indicators. Between 2010 and 2013, an average of 21 nationally representative household surveys were conducted per year, of which an average of 15 were conducted annually in the African Region. Fifty countries had at least one household survey over the 3-year period 20112013, of which 34 were in the African Region (about 79% of all countries with ongoing transmission in 2013) (Figure 7.5). The key indicators most commonly measured were those on the availability and use of ITNs and IPTp (Table 7.1). Surveys that include questions on the proportion of fever cases receiving a nger stick or heel prick have become more common since 2009, when it was rst recommended as a standard malaria indicator (1). However, it was still included in only 25% of surveys conducted between 2011 and 2013, compared to the proportion that enquired about malaria treatment (90%). There has been a pronounced increase in the number of surveys that measure parasite prevalence since 2005, with 81% of all surveys conducted between 2011 and 2013 including measurement of
WORLD MALARIA REPORT 2013 | 51

Figure 7.5 Countries with at least one household survey over the 3-year period 20112013

No households surveys from 2011 through 2013 At least 1 household survey from 2011 through 2013
Source: Household surveys

Figure 7.6 Number of household surveys between 2000-2013 by number of cases expected to occur in a country in 2000
10 Number of househlds surveys undertaken 20002013 8 6 4 2 0 1
Source: Household surveys, WHO estimates

100

10 000 Estimated number of malaria cases, 2000

1 000 000

100 000 000

parasite prevalence. The under-5 mortality rate was commonly measured, being included in all DHS and MICS (but generally excluded from MIS, for which sample sizes are insucient to measure with precision). In contrast to routinely reported data, household surveys are more commonly undertaken in countries with the highest number of malaria cases (Figure 7.6), possibly because of the poor quality of routine data available.

submitted to WHO. Thus, information systems are weakest where the malaria burden is greatest. In contrast to routinely reported data, household surveys are more commonly undertaken in countries with the highest number of malaria cases. Fifty countries, of which 34 were in the African Region, had at least one household survey over the 3-year period 20112013. Indicators most commonly measured were those on the availability of ITNs. Only 25% of surveys included questions on fever cases receiving a nger prick or heel stick, whereas 90% enquired about malaria treatment a nding that will need to change if progress towards universal diagnostic testing is to be tracked. The number of surveys that measure parasite prevalence has increased since 2005, rising to 81% of surveys conducted between 2011-2013.. The all-cause under-5 mortality rate is the most commonly measured indicator across surveys. Nationally representative household surveys are not generally appropriate for countries that are in the pre-elimination or elimination phase, in which malaria is highly focal and is best monitored through intensive surveillance. In countries with a low incidence of malaria the large sample sizes required may prohibit the measurement of some malaria indicators (e.g.

7.4 Conclusions
Routine health information systems detected only 14% of cases estimated to occur globally in 2012. Case detection rates were lowest in countries with the highest numbers of malaria cases. The proportion of deaths that are reported is also lowest in countries with the greatest number of malaria deaths. Surveillance systems do not need to detect all cases in order to reliably assess trends; however, case detection eorts do need to be reasonably uniform over time. Countries with fewer estimated cases of malaria appear to be most able to assess trends in incidence. In the 41 countries that account for 85% of estimated cases, it is not possible to reliably assess malaria trends using the data
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Table 7.1 Proportion of surveys in which key indicators were measured For calculation of proportions the denominator for malaria specic indicators is the number of surveys with malaria specic questions. For all-cause under-5 mortality rate the denominator is total surveys undertaken.
20002013 Number Proportion 20112013 Number Proportion

Proportion of population with access to an ITN within their household Proportion of population who slept under an ITN the previous night Proportion of households with at least one ITN for every two people and/or sprayed by IRS within the past 12 months Proportion of women who received three ore more doses of IPTp during ANC visits during their last pregnancy Proportion of children under 5 years old with fever in the past 2 weeks who had a nger prick or heel stick Proportion receiving rst line treatment among children under ve years years of age with fever in the past two weeks who received any antimalarial drugs Parasite prevalence: proportion of children aged 659 months with malaria infection Surveys with malaria specifc questions All-cause under 5-mortality rate (5q0) Total surveys

209 188 58 194 42 209 88 252 288 323

83% 75% 23% 77% 17% 83% 35% 89%

61 60 26 54 16 57 51 63 77 81

97% 95% 41% 86% 25% 90% 81% 95%

ACT, artemisinin-based combination therapy, ANC, antenatal clinic; IRS, indoor residual spraying; IPTp, intermittent preventative treatment in pregnancy; ITN insecticide-treated net Source: Household surveys

antimalarial medicines received and parasite prevalence,) with precision. Nevertheless, household surveys can aid the interpretation of data from routine information systems (e.g. they can provide information on what proportion of fever cases do not use public health facilities). Although household surveys are of widespread utility, on their own they do not supply sucient information for global, national or subnational monitoring of malaria programmes. Programme managers need data on a monthly basis (or more frequently), to determine whether control programmes are progressing as intended or whether programme adjustment is necessary. Moreover, as malaria incidence decreases and becomes more focal, data need to be disaggregated at a ner level to understand where problems remain and where programmes need to be intensied, so general sampling of populations becomes less useful. Thus, surveillance, monitoring and evaluation of malaria requires a combination of household surveys and routine information systems. Household survey data can help in validating and interpreting data from routine information systems, and routine systems can ll in data gaps for years and geographical areas in which surveys are not conducted.

References
1. Household survey indicators for malaria control. MEASURE Evaluation, MEASURE DHS, Presidents Malaria Initiative, Roll Back Malaria Partnership, United Nations Childrens Fund, World Health Organization, 2013 (http://www. ro l l b a c k m a l a r i a . o rg / to o l b ox / d o c s / r b m to o l b ox / to o l _ HouseholdSurveyIndicatorsForMalariaControl.pdf, accessed 29 November 2013). 2. World malaria report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/world_malaria_ report_2012/en/index.html, accessed 15 October 2013). 3. Life expectancy: Geneva, World Health Organization, 2013 (http:// apps.who.int/gho/data/node.main.692, accessed 29 November 2013). 4. Health statistics and health information systems: Completeness and coverage of death registration data. Geneva, World Health Organization, 2013 (http://www.who.int/healthinfo/statistics/ mortcoverage/en/, accessed 29 November 2013).

WORLD MALARIA REPORT 2013 | 53

54 | WORLD MALARIA REPORT 2013

CHAPTER 8

Changes in malaria incidence and mortality

This chapter (i) reviews trends in reported malaria cases for 62 countries that have reported consistently between 2000 and 2012; (ii) summarizes progress towards elimination for countries with low numbers of cases; and (iii) presents estimated numbers of cases and deaths globally and regionally from 2000 to 2012, and the numbers of cases and deaths averted between 2001 and 2012. In considering progress towards international targets, it is preferable to examine changes in malaria case incidence rather than absolute numbers, in order to take into account the expected rise in the number of cases due to population growth over a long period. For example, a 75% reduction in malaria case incidence is equivalent to a 5 percentage point reduction against the baseline per year between 2000 and 2015. Thus, to be on track to achieve the targets, countries need to have reduced the incidence of malaria by at least 60% between 2000 and 2012. Countries that reduced malaria incidence rates by 40%60% between 2000 and 2012 are projected to achieve reductions in malaria case incidence of 50%75% in 2015. A summary of progress by WHO region is provided in Table 8.1, Figure 8.1, in the Regional proles and the following text. In the African Region, of 43 countries with ongoing malaria transmission, 8 countries (Botswana, Cabo Verde, Eritrea, Namibia, Rwanda, Sao Tome and Principe, South Africa and Swaziland) and the island of Zanzibar (United Republic of Tanzania) are on track to achieve reductions in reported malaria case incidence or malaria admission rates of 75% or more. A further two countries (Ethiopia and Zambia) are projected to achieve reductions in malaria admission rates of 50%75% by 2015, and one country (Madagascar) by <50%. An increase in locally acquired cases, from 35 in 2000 to 59 in 2012, was reported from Algeria. An assessment of trends was not possible in the remaining 32 countries in the subregion, owing to changes in health-service access, diagnostic testing or reporting over time. A limited number of research studies suggest that progress in reducing malaria case incidence may be more widespread, but the small scale and lack of representativeness of these studies do not permit an extrapolation of results to a national or wider geographical scale. In the Region of the Americas, reductions in incidence of >75% in microscopically conrmed malaria cases were reported in 13 out of 21 countries with ongoing transmission between 2000 and 2012 (Argentina, Belize, Bolivia (Plurinational state of ), Costa Rica, Ecuador, El Salvador, French Guiana (France), Guatemala, Honduras, Mexico, Nicaragua, Paraguay and Suriname); a further 3 countries are projected to achieve reductions of >75% by 2015 (Brazil, Colombia and Peru). Two countries (the Dominican Republic and Panama) are projected to achieve reductions of 25%50% by 2015. Increases in numbers of cases between 2000 and 2012 were reported by two countries (Guyana and the Bolivarian Republic of Venezuela). In Haiti, the number of reported malaria cases increased, but it is unclear whether the rise is real, or is simply due to changes in the extent of diagnostic testing and reporting. In the Eastern Mediterranean Region, 3 of the 10 countries with ongoing transmission in 2000 (Islamic Republic of Iran, Iraq and
WORLD MALARIA REPORT 2013 | 55

8.1 Introduction
The reported number of conrmed malaria cases can be used as a core indicator for tracking progress towards the World Health Assembly and the Roll Back Malaria (RBM) Partnership targets for 2015 (which are to reduce malaria cases by 75% from 2000 levels), and the Millennium Development Goal (MDG) target of reversing the incidence of malaria. For many high-burden countries in the WHO African Region, where case conrmation remains variable and often inadequate, it is not possible to assess trends in conrmed cases. Therefore, attempts are made to evaluate trends in the reported numbers of malaria admissions (inpatient cases) and deaths. Although the diagnosis of admitted patients is not always conrmed with a diagnostic test, the predictive value of an unconrmed diagnosis for an admitted patient is considered to be higher than for an outpatient, because signs of severe malaria are more specic than those for uncomplicated malaria. A description of the strategy used to analyse trends, and a summary of results for individual countries, is provided in the Country Proles, Section C.1.7. In brief, the strategy aims to exclude data-related factors (e.g. incomplete reporting or changes in diagnostic practice) as explanations for a change in the reported incidence of disease. If changes in diagnostic testing or reporting are large, then it may be concluded that it is not possible to draw inferences about trends in malaria. Of the 103 countries that had ongoing malaria transmission in 2000, 62 were judged to have submitted data that are suciently complete and consistent to reliably assess trends in between 2000 and 2012. Even if trends in health-facility data appear to be real, rather than an artefact of data reporting, they may not reect changes in the entire community. The conclusion that trends inferred from health-facility data reect changes in the community has more weight if: (i) the changes in disease incidence are large; (ii) access to public health services is high; and (iii) interventions that promote a reduction in cases, such as use of insecticide-treated mosquito nets (ITNs), are delivered throughout the community rather than being restricted to some population groups, especially those with better access to health facilities.

Table 8.1 Summary of trends in reported malaria incidence 20002011

50%75% decrease in incidence projected 20002015 <50% decrease in incidence projected 20002015

WHO Region

On track for 75% decrease in incidence 20002015

Increase in incidence 200020122

Insuciently consistent data to assess trends

African

Botswana Cabo Verde Eritrea Namibia Rwanda Sao Tome and Principe South Africa Swaziland

Ethiopia Zambia

Madagascar

Algeria

Angola Benin Burkina Faso*+ Burundi+ Cameroon Central African Republic Chad Comoros Congo Cte dIvoire Democratic Republic of the Congo Equatorial Guinea* Gabon Gambia Ghana Haiti

Guinea Guinea-Bissau Kenya* Liberia+ Malawi Mali Mauritania Mayotte, France Mozambique Niger Nigeria Senegal Sierra Leone+ Togo*+ Uganda*+ United Republic of Tanzania* Zimbabwe+

Region of the Americas

Argentina Belize Bolivia (Plurinational State of) Costa Rica Ecuador El Salvador French Guiana, France Iran (Islamic Republic of) Iraq Armenua Azerbaijan Georgia Kyrgyzstan

Guatemala Honduras Mexico Nicaragua Paraguay Suriname Brazil Colombia Peru Saudi Arabia Afghanistan Tajikistan Turkey Turkmenistan Uzbekistan Nepal Sri Lanka Thailand Democratic Republic of Timor-Leste Solomon Islands Vanuatu Viet Nam Lao Peoples Democratic Republic India

Dominican Republic Panama

Guyana Venezuela (Bolivarian Republic of )

Eastern Mediterranean

Djibouti Pakistan* Somalia

South Sudan Sudan* Yemen*

European

South-East Asia Bangladesh Bhutan Democratic Peoples Republic of Korea Western Pacic Cambodia China Malaysia Philippines Republic of Korea

Indonesia Myanmar+

Papua New Guinea

Source: National Malaria Control Programme reports Countries in prevention of reintroduction phase are not included in this table Countries in bold achieved 75% decrease in case incidence by 2012 * Progress in reducing cases has been reported sub-nationally where interventions have been intensied. + Country has recently expanded diagnostic testing, so assessment of trends is dicult. 56 | WORLD MALARIA REPORT 2013

Figure 8.1 Decreases in reported malaria case incidence rates, 20002012, by WHO region
40 Number of countries 30 20 10 0 AFR 20 Number of countries 15 10 5 0 AMR

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

8 Number of countries 6 4 2 0

EMR

8 Number of countries 6 4 2 0

EUR

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

8 Number of countries 6 4 2 0

SEAR

8 Number of countries 6 4 2 0

WPR

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

Insucent data to assess trends

Increase 20002012

<50% reduction by 2015

5075% reduction by 2015

>75% reduction by 2015

AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacic Region Source: National Malaria Control Programme Data

Saudi Arabia) attained a decrease of more than 75% in case incidence rates in 2012 compared to 2000. No locally acquired cases have been reported in Iraq since 2009. Afghanistan is projected to achieve a reduction of >75% in case incidence by 2015. The number of conrmed cases has uctuated from year to year in the other 6 countries (Djibouti, Pakistan, Somalia, South Sudan1, The Sudan and Yemen), and it is not possible to determine whether malaria case incidence is increasing, decreasing or constant. In the European Region, all of the eight countries with ongoing transmission of malaria in 2000 achieved reductions in case incidence of more than 75% between 2000 and 2012. Only 255 locally acquired cases were reported in 2012, all due to Plasmodium vivax; of these 255 cases, 218 were in Turkey, 13 in Tajikistan, 3 in Azerbaijan and there was 1 introduced case in Georgia. Another 20 cases were reported from Greece after importation of parasites in 2010. Three locally acquired P. vivax cases were also detected in 2013. Despite this setback, the European Region appears to be on track to achieve elimination of malaria by 2015 as planned,
1. In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/ A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region.

provided that countries address the remaining challenges and prevent the reintroduction of malaria transmission. In the South-East Asia Region, of the 10 countries with ongoing transmission, 5 (Bangladesh, Bhutan, the Democratic Peoples Republic of Korea, Nepal and Sri Lanka) registered decreases in the incidence of conrmed malaria cases of 75% or more between 2000 and 2012, and 2 (Thailand and Timor-Leste) are projected to decrease malaria case incidence by more than 75% by 2015. India is projected to reduce case incidence by 50%75% by 2015. In the 2 remaining countries (Indonesia and Myanmar), incidence trends are obscured by changes in diagnostic or reporting practices. In the Western Pacic Region, decreases of more than 75% in the incidence of microscopically conrmed malaria cases between 2000 and 2012 were reported in 8 of the 10 endemic countries (Cambodia, China, Malaysia, the Philippines, the Republic of Korea, Solomon Islands, Vanuatu and Viet Nam). The Lao Peoples Democratic Republic is projected to achieve a decrease of >75% by 2015, although it saw a twofold increase in malaria cases in 2012, primarily due to increased incidence in six southern provinces, which was associated with population movement related to economic development. Papua New Guinea reported an increase

WORLD MALARIA REPORT 2013 | 57

in conrmed cases in 2012 owing to wide extension of diagnostic testing to health facilities that had not previously undertaken testing; otherwise, Papua New Guinea would be on track to achieve a reduction in case incidence of more than 25% since 2000. Based on an assessment of trends in reported malaria cases, a total 59 countries are meeting the MDG target (6.2c) of reversing the incidence of malaria. Of these 59, 52 are on track to meet RBM and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015. The 52 countries accounted for only 8 million (4%) of the total estimated cases of 226 million in 2000. Only 3 countries with more than 1 million estimated cases in 2000 (Afghanistan, Bangladesh and Brazil) are projected to achieve a reduction in malaria case incidence of 75% or more. This is partly because progress has been faster in countries with lower numbers of cases, but it is also inuenced by the poorer quality of surveillance data submitted by countries with larger estimated numbers of cases. Countries with higher numbers of cases are less likely to submit suciently consistent data for assessing trends (Section 7.2); therefore, it is necessary to draw inferences about trends in these countries using estimated numbers of cases rather than surveillance data (Section 8.2).

Altogether, 19 countries were in the pre-elimination and elimination phases in 2013. Their progress is summarized below. In the African Region, Cabo Verde is in the pre-elimination phase, and continues to progress towards eliminating malaria. It reported a total of 36 conrmed malaria cases in 2012, of which only 1 was locally acquired (compared with 18 indigenous cases in 2011). Algeria, which is in the elimination phase, reported only 4 locally acquired cases in 2011 but saw 55 indigenous cases and 3 introduced cases in 2012. The number of imported cases also rose, from 187 in 2011 to 829 in 2012, possibly associated with population movements from sub-Saharan Africa. Both Algeria and Cabo Verde implement active case detection (ACD), case investigation and a quality assurance (QA) system for diagnostic testing guided by a national reference laboratory; they also provide treatment with primaquine for radical cure of P. vivax and clearance of gametocytes in P. falciparum infections. Eight countries in southern Africa are signatories to the Elimination Eight (E8) regional initiative launched in March 2009, a goal of which is to achieve the eventual elimination of malaria in the region, and elimination in four countries (Botswana, Namibia, South Africa and Swaziland) by 2015. These four countries report relatively low numbers of malaria cases Botswana (432), Namibia (194), South Africa (1632), Swaziland (171 conrmed cases and 405 presumed cases). With continued investments in malaria control, it is expected that these countries will continue to progress towards elimination, although they do not yet meet the case management and surveillance criteria to be classied as being in the pre-elimination phase. In the Region of the Americas, Belize moved from the control phase to the pre-elimination phase in 2013, joining six other countries (Argentina, Costa Rica, Ecuador, El Salvador, Mexico and Paraguay). Belize reported 37 cases in 2012, and undertakes ACD, case investigation and radical treatment. Costa Rica, which reported only 6 indigenous cases in 2012; it applies ACD,

8.2 Progress towards elimination

The criteria used to classify countries according to programme phase were updated in 2012, in order to facilitate tracking of progress over time (1). The updated criteria are based on an evaluation of three main components: the malaria epidemiological situation, case management practices, and the state of the surveillance system see Country Proles, Table C.1.). The evaluation concentrates on the situation in districts of the country reporting the highest incidence of malaria. Table 8.2 shows the current classication of endemic countries by programme phase, and the movement between phases over 20122013.

Table 8.2. Classication of countries by stage of elimination, December 2013

Region Pre-elimination Elimination Prevention of re-introduction Recently certied as malaria free

African Region of the Americas

Cabo Verde
Belize

Algeria

Argentina Costa Rica Ecuador El Salvador Mexico Paraguay

Eastern Mediterranean

Iran (Islamic Republic of ) Saudi Arabia

Egypt Iraq Oman Syrian Arab Republic Georgia

Kyrgyzstan Uzbekistan

Morocco - 2010 United Arab Emirates 2007

European

Azerbaijan Tajikistan Turkey Bhutan Democratic Peoples Republic of Korea Malaysia Republic of Korea Sri Lanka

Armenia - 2011 Turkmenistan 2010

South-East Asia

Western Pacic
Source: NMCP reports

58 | WORLD MALARIA REPORT 2013

case investigation, radical treatment of P. vivax malaria and QA of microscopy services. Argentina and Paraguay reported no indigenous cases in 2012. In the Eastern Mediterranean Region, the Islamic Republic of Iran and Saudi Arabia are in the elimination phase. In the Islamic Republic of Iran, the number of indigenous cases was reduced from 1710 in 2011, to 787 in 2012 (comprising 756 indigenous, 12 introduced and 19 suspected relapsing cases). In contrast, there has been a slight increase in the number of indigenous cases in Saudi Arabia during the past 3 years (29 cases in 2010, 69 in 2011

and 82 in 2012) against a background of rising malaria importation (in 2012 there were 2088 imported P. vivax cases and 1197 P. falciparum). Both countries apply intensive surveillance interventions, as well as vector control activities in aected areas. No locally acquired cases have been reported in Iraq since 2009, and the country is in the prevention of reintroduction phase along with Egypt (zero locally acquired cases reported in 2012), and Syria (zero locally acquired cases reported in 2011 and 2012). Oman is also in the prevention of reintroduction phase. It had interrupted transmission of malaria from 2004 to 2006, but has been

Box 8.1 Trends in malaria cases due to P. vivax

Several factors make P. vivax more dicult to control than P. falciparum: P. vivax sporozoites develop faster than those of P. falciparum in Anopheles mosquitoes, and at wider temperature ranges, enabling transmission to occur from younger mosquitoes and in a wider variety of geographical conditions; P. vivax has a liver stage that is undetectable by current diagnostic techniques and is unresponsive to drugs commonly used to treat blood stages the one drug used to treat the liver stage can cause severe side-eects (haemolysis) in patients who are decient in the metabolic enzyme, glucose-6-phosphate dehydrogenase (G6PD); and once an infection occurs in a human, gametocytes (the form of the parasite that can infect mosquitoes) appear more quickly than those of P. falciparum, and are transmitted more eciently to mosquitoes, such that most patients can transmit to mosquitoes before a case is diagnosed. As a result of these characteristics, it is expected that P. vivax will respond more slowly to control measures. However, dierences in the rates at which each parasite decreases are not always obvious. When aggregated at national level, data may conceal variation in case detection eorts over time. For example, a decrease in reported malaria cases overall in India between 2005 and 2009 occurred at the same time as increased eorts at case detection in Odisha state, where P.falciparum is more common; as a result, the number of reported P.falciparum cases decreased more slowly than those of P. vivax. In addition, when the total number of cases in a country decreases to low levels, then case counts are increasingly inuenced by the number of imported cases, which reect where patients have been travelling rather than the predominant species of malaria locally. For example, in China, only 9 locally acquired cases of P. falciparum and 133 of P. vivax were reported in 2012, compared to 1403 and 39 imported cases, respectively (there were also 2 locally acquired mixed infections and 39 imported cases). Despite the potential for trends to be distorted, it is apparent that, among the 62 countries in which reported data on numbers of cases is suciently consistent to assess trends, decreases in P. falciparum incidence are generally larger than those of P. vivax (Figure Box 8.1). Moreover, in all countries in which malaria is microscopically conrmed, the proportion of cases due to P. falciparum is larger in years with more cases than in years with fewer cases (Figure Box 8.2). As a result of the slower rates of decrease in the incidence of P. vivax, many malaria control programmes that are moving towards elimination are needing to give greater attention to the control of P. vivax, particularly in countries outside sub-Saharan Africa. Indeed, P. vivax predominates in countries in the pre-elimination and elimination phases (Figure Box 8.3).
Figure Box 8.1a Proportion of cases due to P. falciparum in years with the highest incidence of disease 20002012, versus proportion of cases due to P. falciparum in years with lowest incidence 20002012
Proportion of cases due to P. falciparum during three years with highest case incidence

100% 80% 60% 40% 20% 0%

0% 20% 40% 60% 80% 100%

y=x

Proportion of cases due to P. falciparum during three years with lowest case incidence
Source: NMCP reports

Figure Box 8.1b Percentage reduction in case incidence by parasite species for countries in which it is possible to assess trends from reported data
Reduction in malaria case incidence, 20002012

0% 20% 40% 60% 80% 100%

P. falcimarum P. vivax

Source: NMCP reports

Figure Box 8.1c Percentage of malaria cases due to P. falciparum by programme phase outside of sub-Saharan Africa, 2012
Proportion of cases due to P. facliparum, 2012

0% 20% 40% 60% 80% 100%

Control Pre-elimination and elimination

Source: NMCP reports

WORLD MALARIA REPORT 2013 | 59

battling small outbreaks since 2007 involving both P. falciparum and P. vivax. In 2012, the country reported 2051 cases, all parasitologically conrmed, of which only 22 were locally acquired. Oman is applying a prevention of reintroduction strategy, with general health services vigilant for the occurrence of any new cases, and case investigation followed by outbreak response as needed. In the European Region, three countries are in the elimination phase and together reported just 255 locally acquired cases in 2012, all due to P. vivax, of which 218 were in Turkey, 13 in Tajikistan and 3 in Azerbaijan. In Turkey, as a result of P. vivax importation by international truck drivers, and a delay in the recognition of an index case, a malaria outbreak occurred in one village in the province of Mardin, with 219 cases (1 imported, 1 introduced and 217 indigenous). By conducting a massive scale-up of control and surveillance interventions including vector control through indoor residual spraying (IRS), screening of populations most at risk and directly observed radical treatment the national malaria control programme (NMCP) promptly contained the outbreak. Georgia, Kyrgyzstan and Uzbekistan are in the prevention of reintroduction phase. Indigenous malaria cases were last detected in these countries in 2010 (Georgia reported one introduced case in 2011 and one in 2012, as a result of malaria importation by migrant workers). In all these countries, malaria is a notiable disease; that is, each case and focus is epidemiologically investigated and classied, QA of microscopy is carried out by a national reference laboratory and there is radical treatment of P. vivax cases. The year 2010 marked the start of renewed local P. vivax transmission in the Lakonia region of Greece, after importation of parasites. Containment interventions were applied, with a focus on both migrant workers and local residents in high-risk areas (including establishment of a functional system for early detection that included ACD, prompt radical treatment of cases, reinforced surveillance, strengthening of institutional capacities of health

services at all levels, better targeted IRS, and improved intersectoral collaboration and public awareness). The localized outbreak of malaria reported recently in the Lakonia region was successfully contained. In 2012, the number of locally acquired cases in Lakonia dropped to 20 (alongside 60 imported cases) and to zero in 2013 (to November 2013). However, two locally acquired P. vivax cases were detected in the Municipality of Alexandroupolis, Evros, and one in the Municipality of Sofades, Karditsa, in addition to 17 imported cases, of which 10 were reported from immigrants from malaria-endemic countries. Greece continues to work to prevent the reintroduction of malaria. The European Region is close to attaining the goal of eliminating malaria from the region by 2015, as set out in the 2005 Tashkent Declaration. Nonetheless, the experience of Greece and Turkey highlights the persistant threat of reintroduction and the need for continued vigilance to ensure that any resurgence is rapidly contained. In the South-East Asia Region, Bhutan and the Democratic Peoples Republic of Korea are in the pre-elimination phase, and Sri Lanka in the elimination phase. Bhutan reported a total of 82 locally acquired cases in 2012, down from 228 in 2011. The number of people living in the 26 active foci is still high (518 000). All cases in these three countries are microscopically conrmed by quality-assured laboratories. Malaria is a notiable disease, with each case investigated and reported by districts to the central level on a weekly basis. There has been a rise in the number of P. vivax cases in the Democratic Peoples Republic of Korea, from 13 383 in 2010, to 15 633 in 2011 and 21 850 in 2012. The number of active foci remains high (146) and >50% of the population lives in malariaendemic areas. The situation calls for strengthening of vector control interventions, and responsive surveillance aiming at fast reduction of transmission and foci clearance. In Sri Lanka, the

Box 8.2 Malaria burden estimation evidence review group

In 2012, the MPAC endorsed the creation of an ERG on malaria burden estimation that would make recommendations on: 1. What approaches WHO should use to: a) estimate the number of malaria cases and deaths occurring in a country, in order to prioritize countries for resource allocation decisions; b) understand trends over time, in order to assess the success of global strategies; and c) prioritize malaria in comparison with other health conditions. 2. What approaches endemic countries should use to: a) estimate the number of malaria cases and deaths national and subnationally; and b) understand which populations are most badly aected.1 The ERG met three times between September 2012 and June 2013, and invited key researchers in the eld of malaria burden estimation. Its principal recommendations were as follows: a) For 2013, WHO should use the same methodology for case estimation as is currently used. In 2014 and thereafter, for African countries without strong surveillance systems, WHO should derive estimates
1. See http://www.who.int/malaria/mpac/evidencereviewgroups/en/index. 60 | WORLD MALARIA REPORT 2013 html for Terms of reference and list of members of the ERG.

of the number of cases from estimates of parasite prevalence generated by the Malaria Atlas Project (MAP). In other countries, it should continue to use existing methodologies, but should further investigate assumptions about parasitaemia and dierent care-seeking behaviours. To facilitate this, data on parasite prevalence from household surveys should be stratied by type of care-seeking behaviour. b) WHO should use the same methodology for the World malaria report 2013 malaria mortality estimates as is presently used. However, further research should be conducted, particularly in relation to the age structure of malaria deaths, including (i) a review of data from selected hospitals in Africa to explore further the age distribution of severe malaria and death; and (ii) a review of published and unpublished data from health facilities or intervention trials. c) WHO should report on parasite prevalence as a key morbidity indicator (in addition to cases and deaths). As with cases and deaths, the World malaria report will show country-reported parasite prevalence values and modelled parasite prevalence. d) WHO should develop user-friendly and transparent methods for generating country-level estimates of prevalence, cases and deaths. This will increase country ownership over the estimates, which should, in turn, encourage more investment in data quality.

number of cases continues to decline rapidly, from 684 in 2010, to 124 in 2011 and 23 in 2012. The number of the active foci was reduced to 17, with 500 000 people living in these foci. The NMCP applies reactive and proactive ACD (including mass screening), compulsory notication of cases within 24 hours using text messaging (SMS), case and focus investigation, quality-assured microscopic diagnosis of cases, radical treatment for P. vivax malaria and gametocytocidal treatment of P. falciparum cases. In the Western Pacic Region, Malaysia is in pre-elimination phase and the Republic of Korea in the elimination phase. In Malaysia, there has been a progressive decrease of malaria cases over recent years, with 3662 indigenous cases and 35 introduced cases reported in 2012. Malaria transmission is limited mainly to Sabah and Sarawak, occurring among 3134 active foci with a population of 1.2 million. In the Republic of Korea there has been a marked decline in locally acquired cases, from 1267 in 2010 to 394 in 2012. There are still 22 active malaria foci with a population of 3.8 million. China is on the brink of eliminating malaria from Hainan province, which has a population of 8.8 million, and reported no indigenous cases in 2012 (13 imported cases). Yunnan is the province with the highest malaria burden, and it has a population of 49 million; this province reported a total of 853 cases in 2012 (679 imported), down from 1321 in 2011. The Philippines is progressing with eliminating malaria in some provinces, and has declared 28 of its 80 provinces to be free of malaria. The number of conrmed malaria cases nationwide in 2012 was 7133. The most aected provinces are Maguindanao, Palawan and Tawi-Tawi. The Philippines is progressively meeting the pre-elimination criteria regarding surveillance systems and case management; for example, all suspected malaria cases are conrmed by quality-assured microscopy and there is a national policy for radical treatment. However, the worst aected malaria-

endemic areas of the Philippines are still in the control phase; thus, the country is classied as being in control phase.

8.3 Trends in estimated malaria cases and deaths

Surveillance systems do not capture all malaria cases occurring in a country, and the data reported to WHO are not suciently reliable to assess trends in some countries (Chapter 7). It is therefore necessary to use estimates of the total number of cases or deaths occurring in countries to make inferences about trends in malaria cases and deaths in some countries and at regional and global levels. The methods for producing estimates either (i) adjust the number of reported cases to take into account the proportion of cases that are not captured by a surveillance system; or (ii) for countries with insucient surveillance data, produce estimates using a modelled relationship of case incidence and mortality rates that takes into account malaria transmission intensity and vector control coverage (Country Proles, Section C.1.9). These estimates help to make numbers more comparable between countries, and ll gaps where data are missing. However, the estimates are limited in that they rely on relationships between variables that are uncertain, and draw upon data that may have been imprecisely measured, or measured in previous years and projected forward. Thus, estimates of the number of malaria cases or deaths are accompanied by a large degree of uncertainty, and inferences concerning trends are less certain than those made directly from good-quality surveillance data. In 2012, the Malaria Policy Advisory Committee (MPAC) endorsed the creation of an evidence review group (ERG) on malaria burden estimation, to advise WHO on what approaches to use to estimate the number of malaria cases and deaths occurring in a country. The MPAC proposed that revisions be made in the methodology, beginning in 2014; a summary of its recommendations is shown in Box 8.2.

Table 8.3 Estimated number of (a) malaria cases and (b) malaria deaths by WHO region, 2012
a) Region Estimated cases (000s) Estimate Lower Upper Estimated P. vivax cases (000s) Estimate Lower Upper P. vvax as % of total cases

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic World Outside sub-Saharan Africa
b) Region

165 000 800 13 000 2 27 000 1 000 207 000 33 300

93 000 700 10 000 2 22 000 1 000 135 000 28 000

245 000 1 000 18 000 2 33 000 2 000 287 000 39 400

1 900 500 3 700 2 13 000 200 18 900 16 600

1 600 400 3 000 2 10 000 100 16 000 13 800

2 100 600 4 500 2 16 000 300 22 200 19 800

1% 65% 28% 89% 47% 16% 9% 50%

Deaths <5 as % of total

Estimated deaths, all ages Estimate Lower Upper

Estimated deaths, <5 Estimate Lower Upper

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic World Outside sub-Saharan Africa
Source: WHO estimates

562 000 800 18 000 0 42 000 3 500 627 000 50 000

410 000 500 11 000 0 26 000 2 100 473 000 33 000

722 000 1 200 31 000 0 60 000 5 200 789 000 68 000

462 000 230 6 600 0 11 000 1 600 482 000 14 000

386 000 200 5 400 0 9 000 900 408 000 11 000

534 000 270 8 100 0 14 000 2 400 565 000 17 000

82% 27% 37% 22% 26% 46% 77% 28%

WORLD MALARIA REPORT 2013 | 61

Table 8.4 Estimated number of (a) malaria cases and (b) malaria deaths by WHO region, 20002012
a) Number of cases (000s) 2000 2001 2002 2003 2004 2005 2006 2007

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic World Lower bound Upper bound
b) Number of deaths

174 000 2 000 16 000 31 000 3 000 226 000 151 000 304 000

178 000 2 000 16 000 31 000 3 000 229 000 153 000 307 000

182 000 2 000 16 000 29 000 2 000 231 000 152 000 312 000

187 000 2 000 16 000 30 000 2 000 236 000 156 000 319 000

190 000 2 000 15 000 31 000 3 000 240 000 158 000 325 000

192 000 2 000 13 000 34 000 2 000 244 000 160 000 329 000

190 000 1 000 14 000 29 000 2 000 236 000 154 000 322 000

185 000 1 000 13 000 26 000 2 000 227 000 149 000 313 000

2000

2001

2002

2003

2004

2005

2006

2007

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic World Lower bound Upper bound
Source: WHO estimates

802 000 2 100 22 000 3 49 000 6 900 881 000 670 000 1 113 000

804 000 1 900 22 000 3 45 000 5 800 878 000 666 000 1 113 000

804 000 1 700 22 000 2 43 000 5 100 876 000 664 000 1 110 000

800 000 1 700 22 000 1 43 000 5 700 872 000 662 000 1 102 000

791 000 1 600 20 000 1 45 000 6 100 864 000 656 000 1 094 000

779 000 1 700 20 000 49 000 4 700 854 000 644 000 1 076 000

737 000 1 500 19 000 43 000 4 900 806 000 613 000 1 015 000

714 000 1 300 19 000 40 000 4 100 778 000 595 000 985 000

Estimates of cases and deaths are accompanied by wide uncertainty intervals; nevertheless, they can provide useful insight into the distribution of malaria across countries and trends over time. The remainder of this chapter analyses the global distribution of the estimated numbers of cases and deaths in 2012, and of trends in estimates of malaria cases and deaths from 2000 to 2012.

the South-East Asia Region (13%) and the Eastern Mediterranean Region (6%). About 9% of estimated cases globally are due to P. vivax, although the proportion outside the African continent is 50%. The number of cases was estimated to have increased from 226 million in 2000 to 244 million in 2005, before decreasing to 207 million in 2012 (Table 8.4). The estimated number of malaria cases per 1000 persons at risk of malaria (which takes into account population growth over time) shows a reduction in case incidence of 29% globally between 2000 and 2012, and 31% in the African Region. Decreases are greatest in the

8.3.1 Estimated cases

In 2012, worldwide, there were an estimated 207 million cases of malaria (95% uncertainty interval, 135287 million) (Table 8.3). Most of these cases (80%) were in the African Region, followed by
Figure 8.2 Percentage change in malaria mortality rates, 2000-2012

Percentage change
<25% Decrease 25%-49% Decrease 50%-74% Decrease =75% Decrease No malaria deaths, malaria endemic country Malaria free Not applicable

Source: WHO estimates

62 | WORLD MALARIA REPORT 2013

2008

2009

2010

2011

2012

181 000 1 000 13 000 29 000 2 000 225 000 146 000 307 000

176 000 1 000 12 000 29 000 2 000 219 000 142 000 300 000

170 000 1 000 12 000 28 000 2 000 214 000 140 000 293 000

165 000 1 000 13 000 25 000 1 000 206 000 133 000 285 000

165 000 1 000 13 000 27 000 1 000 207 000 135 000 287 000

462 000 of deaths occurred in children under 5 years of age in the African Region (uncertainty interval, 386 000534 000). Most of the deaths were due to P. falciparum; however, P. vivax is increasingly recognized as a cause of severe malaria and death (Box 8.3). The estimated number of deaths fell in all regions between 2000 and 2012 although there was some uctuation year by year (Table 8.4). During the same period, the population at risk for malaria increased by 39%. Malaria mortality rates, which take into account population growth, are estimated to have decreased by 45% globally across all age groups between 2000 and 2012, and by 51% in children under 5 years of age. In the African Region, malaria death rates decreased by 49% across all age groups and by 54% in children under 5 years of age (Figure 8.2). If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates globally across all age groups will have decreased by 56%, and by 63% in children under 5 years of age, by 2015; whereas, in the African Region they are projected to decrease by 62% in all age groups and by 68% in children under 5 by 2015. There is considerable uncertainty associated with the calculated reductions in mortality rates, since they are based on the estimated numbers of deaths which have wide uncertainty intervals (Figure 8.3). The pace of decrease in estimated malaria mortality rates was initially slow, but it accelerated from 2005. Between 2007 and 2011, the rate of decline was suciently fast to achieve a 75% reduction over 15 years (the plotted points are parallel to the target line in Figure 8.3). However, the decrease in malaria mortality rates was slower between 2011 and 2012. Of the 103 countries that had ongoing transmission in 2000, 60 are projected to achieve reductions in malaria mortality rates of >75% in 2015, or to maintain zero malaria deaths. The rate of decrease is faster than reported previously in the World Malaria Report 2011 (2) and 2012 (1). Two factors are responsible: (i) a steeper rate of decline in the total number of deaths of children under 5 years of age from all causes following revisions to the under-5 mortality envelope by the United Nations (UN) Inter-agency Group for Child Mortality Estimation (the number of deaths was estimated to decrease from 9.6 million globally in 2000 to 7.6 million in 2010 in previous estimates, compared to a decrease from 9.7 million deaths globally in 2000 to 7.0 million in 2010 in the current estimates); and (ii) changes in the proportion

2008

2009

2010

2011

2012

677 000 1 000 18 000 46 000 3 900 747 000 569 000 937 000

647 000 1 200 17 000 48 000 5 000 718 000 547 000 901 000

608 000 1 200 18 000 46 000 3 900 676 000 516 000 851 000

575 000 900 18 000 41 000 3 400 640 000 485 000 804 000

562 000 800 18 000 42 000 3 500 627 000 473 000 789 000

European Region (100%), Region of the Americas (71%) and Western Pacic Region (64%). If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria case incidence is projected to decrease by 36% globally and 39% in the African Region by 2015.

8.3.2 Estimated deaths

There were an estimated 627 000 malaria deaths worldwide in 2012 (95% uncertainty interval, 473 000789 000) (Table 8.3). It is estimated that 90% of deaths in 2012 were in the African Region, followed by the South-East Asia Region (7%) and Eastern Mediterranean Region (3%). About 482 000 malaria deaths (uncertainty interval, 408 000565 000) were estimated to occur in children under 5 years of age, or 77% of the global total. An estimated

Figure 8.3 Estimated malaria mortality rates, 20002012 in (a) all age groups and (b) children <5 years of age
(a) Malaria deaths per 100 000, 20002012 Estimated 75% target Malaria deaths per 100 000, 20002012 (b) Estimated 75% target

60 50 40 30 20 10 0 2000 2005 2010 2015

60 50 40 30 20 10 0 2000 2005 2010 2015

Source: WHO estimates

WORLD MALARIA REPORT 2013 | 63

of deaths attributed to malaria in the current estimates after the addition of more input data to the verbal autopsy model used to estimate the proportion of child deaths due to dierent causes (a total of 47 study data points were used compared to 30 in the previous estimates). As a result, the proportion of global deaths in children under 5 years of age that are due to malaria rose from 6.6% in 2000 to 7.4% in 2010 in the previous estimates, but has fallen from 7.8% in 2000 to 7.6% in 2010 in the current set of estimates (and to 7.3% in 2012). Geographical distribution of cases and deaths About 80% of malaria deaths in 2012 are estimated to occur in just 17 countries, and 80% of cases in 18 countries (Figure 8.4).

For P. vivax cases, four countries account for more than 80% of estimated cases (Ethiopia, India, Indonesia and Pakistan). The global burden of mortality is dominated by countries in subSaharan Africa: the Democratic Republic of the Congo and Nigeria together account for 40% of the global total of estimated malaria deaths and 32% of cases. International targets for reducing cases and deaths will not be attained unless considerable progress can be made in these countries. In 2012, WHO, along with the RBM and other partners, launched a situation room to provide focused strategic support to 10 high-burden countries in sub-Saharan Africa (see Box 8.4).

Table 8.5. Estimated cases and deaths averted by reduction in incidence and mortality rates between 2000 and 2012
Region Cases averted, 20012012 (millions) Percentage of total Deaths averted, 20012012 (millions) Percentage of total

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic World
Source: WHO estimates

337 14 66 0,4 67 15 500

67% 3% 13% 0% 13% 3% 100%

3.08 0.01 0.09 0.11 0.04 3.32

93% 0% 3% 0% 3% 1% 100%

Box 8.3 Severe malaria due to Plasmodium vivax

Plasmodium vivax infection has been associated with severe malaria and death, although the risk of severe P. vivax malaria and case fatality rates (CFRs) are not well dened.1 Comorbidities are considered important contributors to severe complications of P. vivax infection. In particular, concomitant malnutrition is suspected to increase the risk of severe vivax disease, but again this is not well understood. Notably, healthy travellers from non-malaria-endemic countries and healthy residents of low-endemicity regions rarely develop severe disease with P. vivax infection. The risk of severe P.vivax disease in residents of endemic areas has been observed to rise with increasing transmission intensity, although the contribution of less access to care and more co-morbidities in these settings is not well quantied. The spectrum of reported severe P. vivax syndromes is similar to that with P. falciparum; however, the relative frequency and signicance of each syndrome diers between severe vivax and severe falciparum disease. Clinical manifestations of severe P. vivax malaria include severe anaemia (<5 mg haemoglobin/dL), acute respiratory distress syndrome (ARDS), acute kidney injury and splenic rupture. P. vivax infection in pregnant women has also been associated with spontaneous abortion and intrauterine growth retardation. Coma and other neurological complications are rare. Metabolic acidosis and coma occur less frequently in severe P. vivax malaria. Mortality from severe anaemia and acute lung injury the most commonly reported manifestations of severe P. vivax is less frequent in P. vivax than in P. falciparum infection.
1. For a full discussion see Anstey et al, Plasmodium vivax: Clinical Spectrum, risk factors and pathogenesis, in Hay SI, Price R, Baird JK, eds, The Epidemiology of Plasmodium Vivax: History, Hiatus and Hubris, Part A., Advances in 64 | WORLD REPORT 2013 Parasitology , Oxford:MALARIA Academic Press, 2012, vol 80: pp 151-201

Severe P. vivax malaria is characterized by lower blood-stage parasitaemia than is observed in severe falciparum cases. Unlike P. falciparum, P. vivax-associated pathogenesis is not associated with signicant microvascular obstruction of vital organs. Nevertheless, low blood-stage parasitaemia may be masking parasite sequestration outside the vascular system (e.g. in the spleen), which may explain how severe syndromes can develop at relatively low levels of parasitaemia. The severity of anaemia observed with low parasitaemia may also be due to the cumulative impact of multiple relapses of disease, as is the norm for most P. vivax infections. The population-based risk of severe disease and CFRs for P. vivax infection have been examined in only a small number of studies and reports of severe P. vivax are often limited by incomplete investigation into other contributing factors. Some studies have reported similar risks of death among hospitalized patients as for P. falciparum; however, the population-attributable risks of death from the two organisms have rarely been compared. Where such risks have been compared, the risk from P. vivax is less than half that associated with P. falciparum. A rmer evidence base for these risks would support rened estimates of the clinical burden of P. vivax. The demographic risk of severe vivax malaria in regions of relatively high endemicity is skewed towards early infancy (a stage when severe anaemia is a major cause of morbidity), and decreases as immunity builds up into childhood and adolescence. A clearer picture of severe vivax malaria is emerging, but further study is required to rene existing knowledge of the spectrum of syndromes, and their risks of severe morbidity and mortality. Improved data from inpatient settings on hospitalized malaria cases by Plasmodium species, as well as population-based assessments of the risk of severe P. vivax infection, are needed so that the true burden of severe P. vivax malaria can be understood.

Figure 8.4 Cumulative proportion of the global estimated cases and deaths accounted for by the countries with the highest number of (a) cases (b) P. vivax cases (c) deaths and (d) deaths in children under 5 The 80% gridline is highlighted to more easily distinguish countries that account for 80% of the estimated number of malaria cases and deaths in 2012.
Nigeria India Democratic Republic of the Congo Uganda United Republic of Tanzania Mozambique Ghana Indonesia Burkina Faso Sudan Niger Guinea Malawi Ethiopia Cte dIvoire Senegal Angola Zambia Cameroon Kenya Pakistan Chad South Sudan Mali Benin Central African Republic Togo Congo Myanmar Madagascar Liberia Sierra Leone Zimbabwe Papua New Guinea Burundi India Pakistan Indonesia Ethipoia Myanmar Afghanistan Brazil Sudan South Sudan Bangladesh Papua New Guinea Thailand Colombia Cambodia Venezuela (Bolivarian Republic of ) Peru Democratic Republic of Timor-Leste Eritrea Democratic Peoples Republic of Korea Guyana Solomon Islands Lao Peoples Republic Yemen Honduras Nepal Bolivia (Plunational state of) Viet Nam Guatemala Philippines Vanuatu Malaysia China Nicaragua Republic of Korea Panama

0%

20% 40% 60% 80% (a) Cumulative % of cases (all species)

100%

0%

20%

40% 60% 80% (b) Cumulative % of P. vivax cases

100%

Nigeria Democratic Republic of the Congo India United Republic of Tanzania Angola Uganda Niger Mozambique Ghana Chad Burkina Faso Ethiopia Cte dIvoire Mali Kenya Cameroon Guinea Zambia Malawi Indonesia Senegal Benin Sierra Leone Madagascar South Sudan Sudan Togo Central African Republic Congo Rwanda Burundi Somaila Liberia Myanmar Papua New Guinea

Nigeria Democratic Republic of the Congo Angola Niger Chad Mozambique Burkina Faso Uganda Mali Cte dIvoire Guinea Ghana United Republic of Tanzania Cameroon Zambia India Benin Malawi Ethiopia Sierra Leone Senegal Central African Republic Kenya Togo Congo Madagascar Indonesia South Sudan Liberia Burundi Sudan Papua New Guinea Somaila Guinea-Bissau Gambia

0%
Source: WHO estimates

20%

40% 60% 80% (c) Cumulative % of deaths (all ages)

100%

0%

20%

40% 60% 80% (d) Cumulative % of deaths <5 years

100%

Cases and deaths averted, 20012012 An estimate of the number of cases averted and lives saved between 2001 and 2012 can be made by calculating the number of cases and deaths that would have occurred if incidence and mortality rates remained at 2000 levels until 2012 (i.e. there was no progress). The calculated number of cases and deaths can be compared with the estimated number of cases and deaths presented above. Such an analysis indicates

that 500 million fewer cases and 3.3 million fewer malaria deaths occurred between 2001 and 2012 globally than would have occurred had incidence and mortality rates remained unchanged since 2000 (Table 8.5). Of the 3.3 million deaths averted between 2001 and 2012, 3 million (90%) are estimated to be in children under 5 years of age in sub-Saharan Africa, and account for 20% of the 15 million fewer deaths that would have occurred between 2001 and 2012 had 2000 under-5
WORLD MALARIA REPORT 2013 | 65

Box 8.4 The Malaria Situation Room

The Malaria Situation Room is a joint initiative of WHO, the RBM Partnership Secretariat, the African Leaders Malaria Alliance, the Oce of the UN Secretary-Generals Special Envoy for Health MDG Financing and Malaria, and the International Federation of Red Cross and Red Crescent Societies. The Malaria Situation Room provides strategic support to 10 highburden countries in Africa: Burkina Faso, Cameroon, Cte dIvoire, the Democratic Republic of the Congo, Ghana, Mozambique, Niger, Nigeria, Uganda and the United Republic of Tanzania. These 10 countries are estimated to account for more than 389000 malaria deaths each year, representing about 60% of all malaria deaths in Africa in 2012. The Malaria Situation Room experts collate and synthesize malariarelated information on nancial ows, commodities, intervention coverage and disease trends tracking challenges and progress, and identifying bottlenecks that hinder country scale-up of malaria control interventions. Relevant partners are then approached to help resolve the problems identied, and progress in bottleneck resolution is monitored. The aim is to support countries in their eorts to achieve the health-related MDG goals and other global targets as the 2015 MDG deadline nears. The Malaria Situation Room is co-located within WHO Headquarters and the RBM Partnership Secretariat in Geneva, Switzerland, and the WHO Regional Oce for Africa in Brazzaville, Democratic Republic of the Congo. The Bill & Melinda Gates Foundation has generously committed 3 years of operational funding. The 10 Malaria Situation Room countries not only account for substantial malaria cases and deaths, but also have higher malaria incidence and mortality rates and receive less malaria funding per capita than other African countries (Figure Box 8.4). Progress in securing funds, increasing ITN coverage, and reducing morbidity and mortality was initially slower in these 10 countries, but the gap has narrowed in the most recent years. Rates in decline of case incidence and mortality have slowed in more recent years for both these and other African countries.

Figure Box 8.4 Funding ITN coverage and trends in estimated malaria case incidence and mortality rates, 2000-2012, in countries covered by situation room and other African countries.
Proportion of population with access to ITN within their household, 20002012 Funding per capita for malaria control (US$), 20002012 (a) Other Africa Situation room (b) Other Africa Situation room

3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: see Box 3.1

100% 80% 60% 40% 20% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: see Figure 4.2

(c) Estimated malaria incidence per 1000 population, 20002012

Other Africa

Situation room Estimated malria mortality rate per 100 000 population, 20002012

(d)

Other Africa

Situation room

200 180 160 140 120 100 80 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: WHO estimates

500 400 300 200 100 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: WHO estimates

mortality rates applied for each year between 2001 and 2012. Most of the malaria cases averted (67%) have also been in the African Region. Larger percentage decreases in case incidence and mortality rates are seen in countries with the lowest estimated malaria burdens in 2000 (Figure 8.5). However, although progress in reducing incidence and mortality rates has been faster in countries with smaller estimated numbers of malaria cases and deaths, this does not imply a lack of impact in higher burden
66 | WORLD MALARIA REPORT 2013

countries: overall, more cases and deaths have been averted during 20012012 in countries with the highest estimated initial number of cases and deaths (Figure 8.6), with 59% of cases and 69% of deaths averted being in the 10 countries that had the highest estimated malaria burdens in 2000. Not all of the cases and deaths averted can be attributed to malaria control programmes. Some progress is likely to be related to increased urbanization and overall economic development, which lead to improvements in housing and nutrition.

Figure 8.5 Relations between (a) % change in estimated number of cases between 2000 and 2012 versus estimated cases in 2000 and (b) % change in estimated number of deaths between 2000 and 2012 versus estimated deaths in 2000 African Region
% change in case incidence rates 20002012 20% 0% -20% -40% -60% -80% -100% 1 100 10 000 1 000 000 100 000 000 (a) Estimated number of cases 2000
Source: National malaria control programme data, Vital registration database, WHO estimates

Other Regions
20% % change in mortality rates 20002012 0% -20% -40% -60% -80% -100% 1 100

African Region

Other Regions

10 000

1 000 000

100 000 000

(b) Estimated number of deaths 2000

Figure 8.6 Estimated numbers of (a) cases averted in 20002012 versus cases in 2000 and (b) number of deaths averted in 20002012 versus deaths in 2000 African Region
Estimated number of cases averted 20002012 100 000 000 10 000 000 1 000 000 100 000 10 000 1 000 100 100 1 000 10 000 100 000 1 000 000 10 000 000 100 000 000

Other Regions
Estimated number of deaths averted 20002012 1 000 000 100 000 10 000 1 000 100 10 100 1 000 10 000

African Region

Other Regions

100 000

1 000 000 10 000 000 100 000 000

(a) Estimated number of cases 2000

Source: WHO estimates

(b) Estimated number of deaths 2000

8.4 Conclusions
Of the 103 countries that had ongoing malaria transmission in 2000, 62 submitted suciently complete and consistent data on malaria cases between 2000 and 2012 to enable an assessment of trends. Based on these reported data, 59 countries are meeting the MDG target (6.2c) of reversing the incidence of malaria, and 52 of the 59 (including 8 countries of the African Region) are on track to meet RBM and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015. Decreases in the incidence of P. falciparum incidence are, on average, larger than those of P. vivax, suggesting that P. vivax responds more slowly to control measures, possibly because of its biological characteristics. Of 97 countries with ongoing transmission in 2013, 11 are classied as being in the pre-elimination phase of malaria control, and 7 as being in the elimination phase. A further 7 countries are classied as being in the prevention of reintroduction phase. As a result of the slower rates of decrease in the incidence of P. vivax, many malaria control programmes need to give greater attention to the control of P. vivax. In countries where both species are transmitted, P. vivax predominates in those countries that are in the pre-elimination and elimination phases.

The 52 countries that are on track to achieve a 75% reduction in case incidence, as measured through surveillance systems, accounted for only 8 million (4%) of the global total of 226 million estimated cases in 2000. This is partly due to faster progress in countries with fewer cases, but it is also heavily inuenced by the poorer quality of surveillance data submitted by countries with a larger estimated number of cases. In 41 countries that accounted for 80% of cases in 2000, it is not possible to assess trends using reported data because of inconsistencies in the completeness of reporting over time, changes in diagnostic practice or health-service use. Improved surveillance and evaluation in these countries is needed to provide a more complete and accurate picture of the impact of malaria investments. Because countries with higher numbers of cases are less likely to submit suciently consistent data, it is necessary to draw inferences about the distribution of malaria and trends in some countries using estimates of numbers of cases. The estimated numbers of malaria cases and deaths are accompanied by a large degree of uncertainty. In 2012, there were an estimated 207 million cases of malaria worldwide (95%uncertainty interval, 135287 million) and 627 000 malaria deaths (95% uncertainty interval, 473 000789 000). Most of the estimated cases (80%) and deaths (90%) occur in sub-Saharan Africa, and most (77%) of the deaths occur in children under 5 years of age. About 9%
WORLD MALARIA REPORT 2013 | 67

of estimated cases globally are due to P. vivax, although the proportion outside the African continent is 50%. The estimated number of malaria cases per 1000 people at risk of malaria, which takes into account population growth over time, shows a reduction in case incidence of 29% globally between 2000 and 2012 and 31% in the African Region. At these rates, by 2015, malaria case incidence is projected to decrease by 36% globally and by 39% in the African Region. Malaria mortality rates are estimated to have decreased by 45% worldwide between 2000 and 2012, and by 49% in the African Region; they are also estimated to have decreased by 51% globally in children under 5 years of age and by 54% in the African Region. At these rates, by 2015, malaria mortality rates are projected to decrease by 56% globally and by 62% in the African Region. In children under 5 years of age they are projected to decrease by 63% globally and by 68% in the African Region by 2015. The pace of decrease in estimated malaria mortality rates accelerated from 2005, but slowed between 2011 and 2012. This slowing of the decrease in estimated mortality rates is partly because the model that is used to estimate malaria deaths in children under-5 years of age in Africa uses ITN coverage to adjust the proportion of all deaths that are attributed to malaria (Country Proles, Section C.1.9), and ITN coverage attened in 2011-2012 following decreases in funding for malaria control in 2011. More than 80% of estimated malaria deaths occur in just 17 countries, and 80% of estimated cases occur in 18 countries, with the Democratic Republic of the Congo and Nigeria together accounting for 40% of the estimated global total. Targets for reduction of cases and deaths will not be attained unless substantial progress can be made in countries that account for the vast majority of the malaria burden. In 2012, WHO, along with the RBM and other partners, launched a situation room to provide strategic support to 10 high-burden countries in subSaharan Africa. Four countries (Ethiopia, India, Indonesia and Pakistan) account for more than 80% of estimated P. vivax cases. P. vivax infection has been associated with severe malaria and death, although the risks of severe disease and case fatality rates for P. vivax infection have not been rmly established. The presence of comorbidities - in particular, concomitant malnutrition is suspected to increase the risk of severe disease in P. vivax infection, although this risk also remains poorly dened. Further study is required to rene existing knowledge of the spectrum of severe P. vivax malaria, and the risks of severe disease and death with this infection. Progress in reducing malaria case incidence and mortality rates has been faster in countries that had lower numbers of cases and deaths in 2000. However, the majority of numbers of cases and deaths averted between 2000 and 2012 have been in countries that had the highest malaria burdens in 2000. If the malaria incidence and mortality rates in 2000 had remained unchanged over the decade, 500 million more cases and 3.3 million more deaths would have occurred between 2001 and 2012. Most of the malaria cases averted (67%) and lives saved (93%) have been in the African Region. Of the 3.3 million deaths averted between 2001 and 2012, 3 million (90%) are estimated to be in children under 5 years
68 | WORLD MALARIA REPORT 2013

of age in sub-Saharan Africa. They account for 20% of the 15 million fewer deaths that are estimated to have been averted in sub-Saharan Africa since 2000 through overall reductions in child mortality rates. Thus, decreases in malaria deaths have contributed substantially to progress towards achieving the target for MDG 4, which is to reduce, by two thirds, the under-5 mortality rate between 1990 and 2015. There remain many inherent uncertainties in any approach to producing estimates of malaria case incidence and mortality, and to producing analyses based on the estimates. In 2012, the MPAC endorsed the creation of an ERG on malaria burden estimation, to advise WHO on what methods should be used to estimate the number of malaria cases and deaths. Recommendations will be implemented during 2014. The global malaria community needs to increase its eorts to support malaria-endemic countries in improving diagnostic testing, surveillance, vital registration and routine health-information systems, so that accurate information on malaria morbidity and mortality can be obtained to inform and direct programmes.

References
1. World malaria report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/world_malaria_ report_2012/en/index.html, accessed 15 October 2013). 2. World malaria report 2011. Geneva, World Health Organization, 2011 (http://apps.who.int/iris/bitstream/10665/44792/2/97892415644 03_eng_full.pdf, accessed 22 November 2013).

Regional proles
R.1 Graphs used in Regional Proles R.2 Assessing trends in the incidence of malaria R.3 Establishing a link between malaria disease trends and control acitivites R.4 Classication of countries according to malaria programme phase R.5 Regional proles 64 64 65 69 69

African Region
Central Africa

Eastern Mediterranean Region

Liberia Mali Mauritania Niger Nigeria Sao Tome & Principe Senegal Sierra Leone Togo Congo Democratic Republic of the Congo Equatorial Guinea Gabon Afghanistan Djibouti Iran (Islamic Republic of ) Iraq Pakistan Saudi Arabia Somalia South Sudan Sudan Yemen

Algeria Benin Burkina Faso Cabo Verde Cte dIvoire Gambia Ghana Guinea Guinea-Bissau
West Africa

European Region
Azerbaijan Georgia Kyrgyzstan Tajikistan Turkey Uzbekistan

Angola Burundi Cameroon Central African Republic Chad

East Africa and high transmission areas in Southern Africa

Comoros Eritrea Ethiopia Kenya Madagascar Malawi Mozambique

Rwanda Uganda United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia

South-East Asia Region

Bangladesh Bhutan Democratic Peoples Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste

Low transmission Southern African Countries

Botswana Namibia South Africa

Swaziland Zimbabwe

Region of the Americas

Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of )

Western Pacic Region

Cambodia China Lao Peoples Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

WORLD MALARIA REPORT 2013 | 69

70 | WORLD MALARIA REPORT 2013

This section (i) describes the graphs used in the regional proles, and (ii) summarizes trends in malaria case incidence and their link to malaria programme implementation by WHO region. The following maps and graphs are shown for each WHO region: Figure A. Population at risk: The population at high risk for malaria is that living in areas where the incidence of parasitologically conrmed is more than 1 per 1000 per year (dened at the second or lower administrative level). The population at low risk for malaria is that living in areas with >0 but 1 case of malaria per 1000 per year. Figure B. Percentage of cases due to P. falciparum: The percentage of conrmed cases in which P. falciparum or a mixed infection was detected, calculated as the total number of P. falciparum and mixed infections between 2008 and 2012, divided by the number of positive cases between 2008 and 2012. Figure C. Annual blood examination rate (ABER): Calculated as the number of slide and rapid diagnostic test (RDT) examinations carried out between 2008 and 2012, divided by the population at risk for malaria between 2008 and 2012. Figure D. Change in malaria case incidence: The percentage change in the incidence of reported conrmed cases between 2000 and 2012 (decrease, downward bars; increase, upward bars). For countries in the WHO African Region, the gure shows percentage reductions in the rate of hospital admissions (except for Algeria, Cabo Verde and Sao Tome and Principe, and ve countries in low-transmission south-east Africa, where incidence of reported conrmed cases are used) and in the rate of reported malaria deaths. Although the diagnosis of admitted patients is not always conrmed with a diagnostic test, the predictive value of diagnosis undertaken for an admitted patient is considered to be higher than for outpatient diagnosis that is based only on clinical signs and symptoms. Figures E and F. The numbers of cases (or admissions) for each country between 2000 and 2012: Countries are divided into those that are on track to achieve a >75% decrease in case incidence by 2015, using 2000 as the baseline (Figure G) and those that are projected to achieve a decrease of 75%, incur an increase, or for which reported data are insuciently consistent to make an inference about trends (Figure H). A 75% reduction in malaria case incidence is equivalent to a 5% reduction per year between 2000 and 2015. Thus, to achieve a reduction of 75% by 2015, countries need to have reduced the incidence of malaria by at least 60% between 2000 and 2012. Countries that reduced malaria incidence rates by 40%60% between 2000 and 2012 are projected to achieve reductions in malaria case incidence of 50%75% in 2015. Figure G. Percentage of population at risk protected with IRS and ITNs: The horizontal scale shows the estimated proportion of the population at risk for malaria protected by preventive programmes with IRS and ITNs. For the WHO African Region and for Djibouti, Somalia, South Sudan and the Sudan in the Eastern Mediterranean Region, the proportion of the population with access to an ITN is derived from a model that takes into account household-survey data, ITNs distributed by NMCPs, and ITNs delivered by manufactures (3). For other countries, the propor-

tion of the population protected with ITNs is estimated from the number of ITNs delivered by NMCPs in the past 3 years divided by the population at high risk. It is assumed that each net delivered can cover on average 1.8 people, that conventional nets are re-treated regularly, and that nets are not replaced for at least 3 years. The denominator is the population living at high risk for malaria, since it is assumed that, in countries with lower levels of transmission, ITNs will be preferentially targeted to populations at higher risk. IRS coverage is calculated as the total number of people protected with IRS, divided by the population at high risk. There are limited data on the extent to which these interventions overlap, so the two bars simply represent the percentage of populations protected by the respective interventions individually. Figure H. Percentage of cases potentially treated with antimalarial medicines: Few countries have information systems that record treatments given to individual patients. It is therefore necessary to use aggregate information on numbers of treatment courses delivered to public health facilities, and relate this information to the number of patients attending such facilities. For countries in the WHO African Region, the number of treatment courses available is calculated as the total number of ACT courses delivered by an NMCP, divided by the estimated number of conrmed plus presumed P. falciparum malaria cases attending public health facilities. In other WHO regions, the number of treatment courses available is shown as a percentage of conrmed plus presumed malaria cases reported in the public sector (correcting for reporting completeness). The bars for any antimalarial treatment show the number of all treatment courses supplied in relation to all malaria cases, including those due to P. falciparum. The bars for ACT show the number of ACT treatment courses in relation to the number of P. falciparum cases reported in the public sector. In many countries in subSaharan Africa, patients with clinically diagnosed malaria do not receive a diagnostic test but are presumed to have P. falciparum.

WORLD MALARIA REPORT 2013 | 71

West Africa
Population aected: Approximately 324 million people in the 17 countries of this subregion are at some risk for malaria, with 313 million people at high risk (Figure A). Transmission is generally intense in this subregion except in Cabo Verde and Algeria, which are in the pre-elimination and elimination phases, respectively. Malaria cases are almost exclusively due to P. falciparum (Figure B). Trends in cases and deaths: Cabo Verde has seen consistent decreases in malaria cases since 2000, and in 2012 it reported only one local case and zero deaths for the rst time (Figures D, E). Algeria reported only 4 locally acquired cases in 2011, but 59 in 2012. The number of imported cases also rose from 187 in 2011 to 828 in 2012, possibly associated with population movements from Mali. It was not possible to assess trends in the 14 remaining countries in the subregion because of variation in health service coverage, diagnostic testing or reporting rates over time. In several cases, improved health service coverage and reporting has led to increased numbers of admissions being reported (Figures D, F). Decreases in malaria morbidity and mortality have been reported from limited areas of Burkina Faso (4) and Togo (5, 6), but these research ndings are not sucient to draw conclusions about national trends. Links with antimalarial interventions: The reduction in cases in Cabo Verde appears to be associated with a high coverage of IRS

Country in the pre-elimination phase Cabo Verde Country in the elimination phase Algeria
and delivery of ACTs (Figures G, H). The proportion of the population with access to an ITN within their household is estimated to exceed 50% in 10 countries: Benin, Burkina Faso, Cte dIvoire, Guinea-Bissau, Liberia, Mali, the Niger, Sierra Leone, Senegal and Togo. The use of IRS has increased in the subregion, but coverage remains relatively low. Only seven countries reported delivering sucient antimalarial medicines to treat all patients attending public health facilities: Algeria, Burkina Faso, Cabo Verde, Gambia,, Liberia, Mali and Sierra Leone. Summary: Cabo Verde continues to progress towards eliminating malaria, having reported decreases in malaria case incidence of >75% between 2000 and 2012. Algeria reported an increase in 2012. Several countries in the subregion have improved their levels of intervention coverage, but it was not possible to assess trends in cases or admissions owing to changes in health service access, diagnostic testing or reporting over time.

A Population at risk, 2012

High risk (>1 per 1000)
Benin Burkina Faso Cte dIvoire Gambia Ghana Guinea Guinea-Bissau Liberia Nigeria Sierra Leone Togo Senegal Mali Niger Mauritania Cabo Verde Algeria

B Percentage of cases due to P. falciparum and P. vivax, 20072012

Low risk (1 per 1000) Malaria free
Benin Burkina Faso Cabo Verde Cte dIvoire Gambia Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Ghana Togo Algeria

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

72 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20072012

Liberia Gambia Sierra Leone Niger Togo Cabo Verde Ghana Burkina Faso Guinea-Bissau Mali Senegal Benin Cte dIvoire Nigeria Guinea Algeria Mauritania

D Percentage change in case incidence or admission and death rates, 20002012

Case incidence Admission Death

100%

50%

0%

-50%

Burkina Faso

Guinea-Bissau

Cte dIvoire

Sierra Leone

Ghana

Benin

Cabo Verde

Senegal

Mali

Libetia

Guinea

Niger

Nigeria

Algeria

Togo

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in case incidence of microscopy conrmed cases by 2015
Cabo Verde

F Countries projected to achieve 75% decrease in admission rates by 2015 or with insuciently consistent data to assess trends
Algeria Guinea Bissau Cte dIvoire Niger Sierra Leone Benin Gambia Guinea Senegal Togo Ghana Mali Burkina Faso Nigeria Mauritania Liberia

120 Number of microscopically confirmed cases 100 Number of admissions 80 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2 400 000 2 000 000 1 600 000 1 200 000 800 000 400 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Algeria Benin Burkina Faso Cabo Verde Cte dIvoire Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Algeria Benin Burkina Faso Cabo Verde Cte dIvoire Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo

IRS

ACT

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

WORLD MALARIA REPORT 2013 | 73

Mauritania

Gambia

-100%

Central Africa
Population aected: About 140 million people in 10 countries are at some risk for malaria in this subregion, with 124 million people at high risk (Figure A). Cases are caused exclusively by P. falciparum (Figure B). Trends in cases and deaths: In Sao Tome and Principe, the incidence of conrmed malaria decreased by >75% between 2000 and 2012. Similar decreases were observed in reported malaria admission and death rates (Figures D, E). However, conrmed and admitted cases increased twofold between 2009 and 2012. In the nine remaining countries, it was not possible to assess trends because of incompletely reported data or changes in health service access or diagnostic testing. In several countries, the total number of admissions from all causes increased, suggesting improved health service access that has led to an increase in the number of reported malaria admissions (Figure D). Other evidence of changes in malaria incidence are scarce in this subregion. A study in the Island of Bioko in Equatorial Guinea reported a decrease in parasite prevalence between 2004 and 2011 following scale-up of ITNs and IRS (7), although a recent report indicates that foci of high transmission persist (8). Links with antimalarial interventions: Sao Tome and Principe has high rates of coverage with ITNs (100%), IRS (85%) and diagnostic testing (70%), and has delivered sucient ACTs to treat all patients attending public health facilities. The recent increase in malaria cases and admissions may be related to brief disruptions to spraying activities and supply of ACTs. The proportion of the population with access to an ITN within their household is estimated to exceed 50% in ve countries (Burundi, Cameroon, Chad, Democratic Republic of the Congo and Equatorial Guinea) (Figure G). Angola and Burundi reported delivery of sucient ACTs to treat >50% patients attending the public health facilities (Figure H). Summary: Only Sao Tome and Principe was able to demonstrate decreases in malaria incidence of >75% between 2000 and 2012, but that country has suered some resurgence in recent years. Assessment of trends in case incidence or admissions was not possible in the remaining countries in the subregion, owing to changes in health service access, diagnostic testing or reporting over time.

A Population at risk, 2012

High risk (>1 per 1000)
Angola Central African Republic Congo Equatorial Guinea Gabon Sao Tome and Principe Democratic Republic of the Congo Cameroon Chad Burundi

B Percentage of cases due to P. falciparum and P. vivax, 20072012

Low risk (1 per 1000) Malaria free
Angola Burundi Cameroon Central African Republic Equatorial Guinea Congo Democratic Republic of the Congo Sao Tome and Principe Gabon Chad

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

74 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20072012

Sao Tome and Principe Burundi Angola Democratic Republic of the Congo Gabon Equatorial Guinea Cameroon Congo

D Percentage change in case incidence or admission and death rates, 20002012

Case incidence Admission Death

100%

50%

0%

-50%

Democratic Republic of the Congo

Sao Tome and Principe

Equatorial Guinea

Central African Republic

Cameroon

Angola

Chad

Burundi

Chad Central African Republic

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in case incidence of microscopy conrmed cases by 2015
Sao Tome and Principe

F Countries projected to achieve 75% decrease in admission rates by 2015 or with insuciently consistent data to assess trends
Gabon Chad Equatorial Guinea Congo Burundi Central African Republic Cameroon Angola Democratic Republic of the Congo

60 000 Number of microscopically confirmed cases 50 000 Number of admissions 40 000 30 000 20 000 10 000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

1 800 000 1 500 000 1 200 000 900 000 600 000 300 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of the Congo Equatorial Guinea Gabon Sao Tome and Principe

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of the Congo Equatorial Guinea Gabon Sao Tome and Principe

IRS

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

Gabon

-100%

ACT

100%

WORLD MALARIA REPORT 2013 | 75

East and southern Africa

(excluding low transmission countries in southern Africa)
Population aected: About 274 million people in the 11 countries of this subregion are at some risk for malaria, with 162 million people at high risk (Figure A). About 25% of the population of Ethiopia and Kenya live in areas that are free of malaria. Cases are predominantly due to P. falciparum, except in Eritrea and Ethiopia, where P. vivax accounts for about 45% of cases (Figure B). Trends in cases and deaths: In recent years, almost all the countries have expanded diagnostic testing with RDTs and microscopy, resulting in increases in the number of conrmed cases in most settings. Given the change in diagnostic practice it is necessary to use numbers of malaria admissions to examine changes in malaria incidence over time. Malaria admission rates decreased by >75% in United Republic of Tanzania (Zanzibar) and Rwanda between 2000 and 2012 (Figure D). Malaria case incidence and mortality rates also decreased in Rwanda between 2000 and 2010 (9), but the number of conrmed cases increased between 2011 and 2012 (with similar numbers of cases being tested), reecting the fragility of the gains. Malaria admission rates are projected to decrease by 50%75% in Eritrea and Zambia and by <50% in Madagascar by 2015. Decreases in malaria admission rates were also seen in Mozambique, but the earliest data available are from 2007. In Ethiopia, nationally aggregated data show an increase in admissions, possibly due to an expansion of health services, with >70 hospitals, 2500 health centres, and 16 000 health posts being built since 2005. However, a review of data from 41 hospitals located at <2000 m altitude (malarious areas) indicated a >50% decrease in conrmed malaria cases, admissions and deaths in 2011 compared to 2001. For the other six countries, it was not possible to assess trends nationally, owing to changes in health service accessibility, increased testing or inconsistency of reporting (Figures D, F). Nonetheless, there is evidence of progress being made at least in some parts of some of these countries. In the United Republic of Tanzania, malaria incidence and admission rates decreased by >75% between 2000 and 2012 on the island of Zanzibar. Similar decreases in malaria incidence subnationally have been reported in Kenya (10), Uganda (11) and the United Republic of Tanzania (Mainland) (12). Variation in trends is known to occur within countries (13); hence, it is not possible to infer national trends from these studies. Links with antimalarial interventions: The proportion of the population with access to an ITN in their household was estimated to exceed 50% in nine countries (Eritrea, Ethiopia, Kenya, Madagascar, Mozambique, Rwanda, Uganda, United Republic of Tanzania and Zambia) (Figure G). All the countries except Mozambique distributed sucient ACTs to treat all patients attending public health facilities in 2012 (Comoros did not report) (Figure H). The high coverage of malaria interventions in recent years may partly explain the progress reported in Eritrea, Ethiopia, Rwanda, Zambia and Zanzibar (United Republic of Tanzania). Summary: Malaria admission rates decreased by >75% in Eritrea, Rwanda and Zanzibar (United Republic of Tanzania) between 2000 and 2012, and are projected to decrease by 50%75% by 2015 in Ethiopia and Zambia, and by <50% in Madagascar. In the remaining countries, it was not possible to assess trends in case incidence or admissions owing to changes in health service accessibility, increased testing or inconsistency of reporting.

A Population at risk, 2012

High risk (>1 per 1000)
Malawi Mozambique Rwanda United Republic of Tanzania (Zanzibar) Zambia Comoros Uganda United Republic of Tanzania (Mainland) Eritrea Madagascar Kenya Ethiopia

B Percentage of cases due to P. falciparum and P. vivax, 20072012

Low risk (1 per 1000) Malaria free
Kenya Madagascar Malawi Mozambique Rwanda United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia Uganda Comoros Ethiopia Eritrea

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

76 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20072012

United Republic of Tanzania (Zanzibar) Rwanda Mozambique Malawi United Republic of Tanzania (Mainland) Comoros Kenya Uganda Ethiopia

D Percentage change in case incidence or admission and death rates, 20002012

Case incidence Admission Death

100%

50%

0%

-50%

Eritrea

United Republic of Tanzania (Zanzibar)

Ethiopia

United Republic of Tanzania (Mainland)

Mozambique

Madagascar

Comoros

Rwanda

Zambia

Eritrea Zambia

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in admission rates by 2015

Zambia United Republic of Tanzania (Zanzibar) Eritrea Rwanda

F Countries projected to achieve 75% decrease in admission rates by 2015 or with insuciently consistent data to assess trends
Madagascar United Republic of Tanzania (Mainland) Ethiopia Malawi Comoros Kenya Mozambique Uganda

200 000

2 000 000

100 000 Number of admissions Number of admissions

1 600 000

100 000

1 200 000

80 000

800 000

40 000

400 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Comoros Eritrea Ethiopia Kenya Madagascar Malawi Mozambique Rwanda Uganda United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Comoros Eritrea Ethiopia Kenya Madagascar Malawi Mozambique Rwanda Uganda United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia

IRS

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

WORLD MALARIA REPORT 2013 | 77

Uganda

Malawi

Kenya

Madagascar

-100%

ACT

100%

Low transmission southern African countries

Populations aected: Approximately 15 million people in the ve countries of the low-transmission South African subregion are at some risk for malaria, and 10 million people are at high risk (Figure A). About 80%, or 55 million people, live in areas that are free of malaria. Malaria transmission is highly seasonal. Most malaria cases are caused by P. falciparum (Figure B). Trends in cases and deaths: In 2012, the number of conrmed malaria cases reported in the subregion was 283 000, of which 98% were from Zimbabwe. Four of the ve countries in this subregion (Botswana, Namibia, Swaziland and South Africa) recorded a decrease of malaria case incidence of >75% between 2000 and 2012 (Figure D). The number of reported cases in these four countries decreased by 50% between 2011 and 2012, after some stagnation of their downward trends since 2007. For Zimbabwe, it was not possible to assess trends owing to inconsistent reporting and a change in diagnostic practice (Figures D, F). Reports on conrmed cases are not available from before 2004; the number of patients receiving a diagnostic test tripled between 2007 and 2012, with RDTs increasingly replacing the use of microscopy. Reported malaria deaths in the subregion decreased from 3513 in 2002 (the earliest year for which data from all ve countries are available) to 437 in 2012. Two countries accounted for 96% of reported deaths in 2012: Zimbabwe (80%) and South Africa (16%). Malaria mortality rates have decreased by >75% in each of the ve countries between 2000 and 2012 but the number of malaria deaths has remained relatively stable in South Africa since 2007. Links with antimalarial interventions: In South Africa, where IRS is the primary vector control measure, nearly all of the population at risk was protected in 2012 (Figure G). The number of people with access to an ITN in their household was estimated to exceed 50% in three countries in 2012 (Namibia, Swaziland and Zimbabwe). All of the countries except South Africa and Swaziland reported adequate access to antimalarial medicines (including ACT) in 2012 (Figure H). Summary: Progress in reducing malaria in this subregion has been notable, with four of the ve countries achieving a >75% reduction in case incidence since 2000. It was not possible to assess trends in case incidence in Zimbabwe, owing to inconsistency of reporting over time. All ve countries in the subregion, together with Angola, Mozambique and Zambia, are signatories to the Elimination Eight (E8) regional initiative launched in March 2009, a goal of which is to achieve the eventual elimination of malaria in the region, and to achieve elimination in four countries Botswana, Namibia, South Africa and Swaziland by 2015.

A Population at risk, 2012

High risk (>1 per 1000) Low risk (1 per 1000) Malaria free

B Percentage of cases due to P. falciparum and P. vivax, 20082012

P. falciparum P. vivax Other

Namibia

Botswana

Botswana

Namibia

Zimbabwe

Swaziland

Swaziland

Zimbabwe

South Africa

South Africa

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

78 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012

D Percentage change in incidence of microscopically conrmed cases, 20002012

100%

Zimbabwe

50%
South Africa

Namibia

0%

Botswana

-50%

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in incidence of microscopically conrmed cases by 2015
Botswana South Africa Swaziland Namibia

F Countries projected to achieve 75% decrease in incidence of microscopically cases by 2015 or with insuciently consistent data to assess trends
400 000

South Africa

80 000

Zimbabwe

Number of microscopically confirmed cases

60 000

Number of microspically confirmed cases

300 000

40 000

200 000

20 000

100 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN IRS

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial ACT

Botswana

Botswana

Namibia

Namibia

South Africa

South Africa

Swaziland

Swaziland

Zimbabwe

Zimbabwe

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

Zimbabwe

Namibia

Botswana

Swaziland

Swaziland

-100%

100%

WORLD MALARIA REPORT 2013 | 79

WHO Region of the Americas

Populations aected: In the WHO Region of the Americas, about 120 million people in 21 countries are at some risk for malaria, and 25 million people are at high risk (Figure A). P. falciparum is responsible for <30% of malaria cases overall in the region, although the proportion is more than 50% in Guyana and Suriname and 100% in the Dominican Republic and Haiti (Figure B). Trends in cases and deaths: The number of conrmed malaria cases reported in the region decreased from 1.1 million in 2000 to 469 000 in 2012. Three countries accounted for 76% of cases in 2012: Brazil (52%), Colombia (13%) and Venezuela (Bolivarian Republic of ) (1%). In 13 of the 21 countries (Argentina, Belize, Bolivia, Costa Rica, Ecuador, El Salvador, French Guiana, Guatemala, Honduras, Mexico, Nicaragua, Paraguay, Suriname) malaria case incidence fell by >75% between 2000 and 2012, and three countries (Brazil, Colombia and Peru) are projected to achieve a >75% decrease in case incidence by 2015 (Figures D, E). Two countries (Dominican Republic and Panama) are projected to achieve a decrease of <50% malaria case incidence by 2015 (Figure F). Two countries (Guyana and Venezuela) reported increases in malaria case incidence in 2012 compared to 2000. In Guyana, the number of cases decreased to less than 12 000 during 20072008 but increased to almost 29 000 in 2011 and to more than 32 000 in 2012. The number of cases reported in Venezuela in 2012, almost 53 000, is higher than in any of the previous 12 years. In Haiti, the number of conrmed malaria cases reported increased from 17 000 in 2000 to 25 000 in 2012 but these numbers represent only a small proportion of cases that occur in the country. The number of reported malaria deaths in the region fell from 362 in 2000 to 108 in 2012. Two countries accounted for 78% of reported deaths in 2012: Brazil (59%) and Colombia (19%). These countries registered decreases in malaria mortality rates of 58% and 87% between 2000 and 2012, respectively.

Countries in the pre-elimination phase Argentina Belize Costa Rica Ecuador El Salvador Mexico Paraguay

Links with antimalarial interventions: The decrease in case incidence in this region is not clearly associated with a scale-up of preventive interventions. Only six of the 13 countries (Bolivia, Mexico, Guatemala, Nicaragua, Ecuador and Costa Rica) with >75% decrease had distributed sucient ITNs, or undertaken sucient IRS, to cover >50% of the population at high risk in 2012 (Figure E). Venezuela, which saw an increased number of cases in 2012, reported undertaking sucient IRS to cover 100% of the population at high risk in 2012. Annual blood examination rates exceed 10% in a further four countries (Belize, Paraguay, Peru and Suriname) that are on track to reduce malaria case incidence by 75% (Figures E, G), which may indicate that good access to malaria diagnosis and treatment has helped to reduce malaria case incidence. Summary: The region has made substantial progress in reducing malaria case incidence. Reductions in incidence of >75% in conrmed malaria cases were reported in 13 countries between 2000 and 2012, and a further 3 countries are projected to achieve reductions of >75% by 2015. Six countries are now classied as being in the pre-elimination phase. However, increases in malaria incidence in Guyana and Venezuela indicate a need for intensication of control eorts in some parts of the region. It was not possible to assess trends in Haiti owing to incompleteness and inconsistencies in reporting over time.

A Population at risk, 2012

High risk (>1 per 1000)
French Guiana, France Haiti Guyana Dominican Republic Panama Honduras Belize Ecuador Nicaragua Guatemala Bolivia (Plurinational State of) Costa Rica Colombia Brazil El Salvador Venezuela (Bolivarian Republic of) Peru Suriname Mexico Paraguay Argentina

B Percentage of cases due to P. falciparum and P. vivax, 20082012

Low risk (1 per 1000) Malaria free
Haiti Dominican Republic Guyana Suriname French Guiana, France Colombia Venezuela (Bolivarian Republic of) Nicaragua Brazil Ecuador Peru Honduras Bolivia (Plurinational State of) El Salvador Paraguay Guatemala Panama Belize Costa Rica Argentina Mexico

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

80 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012

Suriname Mexico Paraguay Guyana Nicaragua Peru Belize El Salvador Venezuela (Bolivarian Republic of) Brazil French Guiana, France Panama Dominican Republic Ecuador Colombia Bolivia (Plurinational State of) Guatemala Argentina Honduras Haiti Costa Rica

D Percentage change in incidence of microscopically conrmed cases, 20002012

Change in incidence rate due to all species Change in incidence rate due to P. vivax

100% 50% 0% -50% -100%

0%

20%

40%

60%

80%

100%

E Countries projected to achieve >75% decrease in incidence of microscopically confirmed cases by 2015
Argentina Brazil Colombia Peru Guatemala Honduras Bolivia (Plurinational state of) Nicaragua Suriname Mexico Paraguay French Guiana, France Costa Rica Belize El Salvador Ecuador

F Countries projected to achieve 75% decrease in incidence of microscopically confirmed cases by 2015 or with insufficiently consistent data to assess trends
Panama Dominican Republic Haiti Guyana Venezuela (Bolivarian Republic of)

1 200 000

160 000

Number of microscopy confirmed cases

900 000

Number of microscopy confirmed cases ITN IRS

120 000

600 000

80 000

300 000

40 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Percentage of high risk population potentially protected with IRS or ITNs, 2012
Argentina Belize Bolivia (Plurinational State of) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of)

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Argentina Belize Bolivia (Plurinational State of) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of)

0%

20%

40%

60%

80%

100%

Paraguay Argentina Costa Rica Ecuador El Salvador Belize Suriname Nicaragua Guatemala Mexico Honduras French Guiana, France Bolivia (Plurinational State of) Brazil Colombia Peru Panama Dominican Republic Haiti Guyana Venezuela (Bolivarian Republic of)

ACT

0%

20%

40%

60%

80%

100%

WORLD MALARIA REPORT 2013 | 81

Eastern Mediterranean Region

Populations aected: In 2012, about 300 million people in nine countries in the Eastern Mediterranean Region were at some risk of malaria, and about 100 million people were at high risk (Figure A). Malaria endemicity varies considerably. Seven countries still have areas of high malaria transmission (Afghanistan, Djibouti, Pakistan, Somalia, South Sudan, Sudan and Yemen); transmission is spatially limited in Iran (Islamic Republic of ) and Saudi Arabia; and the last locally acquired case in Iraq was reported in 2009. P. falciparum is the dominant malaria species except in Afghanistan, Iran (Islamic Republic of ) and Pakistan, where most cases are due to P. vivax (Figure B). Trends in cases and deaths: The number of conrmed malaria cases reported in the region decreased from 2 million in 2000 to 1.3 million in 2012. Three countries accounted for 86% of cases in 2012: the Sudan (47%), Pakistan (22%) and South Sudan (17%). Three countries reported >75% decrease in case incidence between 2000 and 2012 (Iran (Islamic Republic of ), Iraq and Saudi Arabia). Iraq has reported zero locally acquired cases since 2009 (Figures D, E). Afghanistan is projected to achieve a >75% decrease in case incidence by 2015. The number of conrmed cases in Pakistan was higher in 20102012 than in previous years, particularly in the districts of Khyber Pakhtoon Khawa, Punjab and Sindh (Figures D, F). However, the increase was associated with increased diagnostic testing and health facility reporting, so the nature of the trend is unclear. Similarly in Djibouti, Somalia, South Sudan and the Sudan it was not possible to make an assessment of trends owing to inconsistent reporting of conrmed cases over time. The reported number of deaths due to malaria has remained relatively stable, with 2166 reported in 2000 and 2307 in 2012 (Annex 6E). However, there are gaps in the data submitted to WHO. Three countries accounted for 95% of reported malaria deaths in 2012: South Sudan (57%), the Sudan (27%) and Pakistan (11%). Links with antimalarial interventions: Four countries had distributed sucient ITNs, or undertaken sucient IRS, to cover
A Population at risk, 2012
High risk (>1 per 1000)
South Sudan Sudan Somalia Pakistan Aghanistan Yemen Saudi Arabia Djibouti Iran Irak

Countries in the elimination phase Iran (Islamic Republic of ) Saudi Arabia

Countries in the prevention of re-introduction phase Iraq Syrian Arab Republic Egypt Oman Countries certied malaria free Morocco, 2010 United Arab Emirates, 2007

>50% of the population at high risk in 2012 (Figure G). Two of these showed reductions in malaria case incidence (Afghanistan and Saudi Arabia), whereas in Djibouti and South Sudan it was not possible to assess trends. Five countries (Iran [Islamic Republic of ], Iraq, Saudi Arabia, South Sudan and the Sudan) reported delivering sucient antimalarial medicines, including ACTs, to treat all patients attending public health facilities, whereas quantities of antimalarial medicines distributed were insucient in Pakistan, Somalia and Yemen. Afghanistan and Djibouti did not report (Figure H). Summary: Three countries in the region (Iran (Islamic Republic of ), Iraq and Saudi Arabia) have reduced malaria case incidence by >75% between 2000 and 2012. No locally acquired cases have been reported in Iraq since 2009 and the country is in the prevention of reintroduction phase. Iran (Islamic Republic of ), Iraq and Saudi Arabia) are in the elimination phase. Afghanistan is projected to achieve a >75% decrease in case incidence by 2015. The number of reported conrmed cases has uctuated from year to year in the other six countries (Djibouti, Pakistan, Somalia, South Sudan, Sudan and Yemen) and it is not possible to determine whether malaria case incidence is increasing, decreasing or constant.
B Percentage of cases due to P. falciparum and P. vivax, 20082012
P. falciparum P. vivax
Djibouti South Sudan Sudan Yemen Somalia Saudi Arabia Pakistan Iran Aghanistan Iraq

Low risk (1 per 1000)

Malaria free

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

82 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012

Djibouti

D Percentage change in incidence of microscopically conrmed cases, 20002012

Change in incidence rate due to all species Change in incidence rate due to P. vivax

100%
South Sudan Sudan

50%
Yemen Somalia

0%
Saudi Arabia Pakistan

-50%
Iran Aghanistan Saudi Arabia Aghanistan Pakistan Somalia Djibouti Yemen Iraq Iran Sudan Iraq South Sudan

-100%

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in incidence of microscopically conrmed cases by 2015
Afghanistan Iran Saudi Arabia Iraq

F Countries projected to achieve 75% decrease in incidence of microscopically cases by 2015 or with insuciently consistent data to assess trends
2 000 000
Somalia Yemen South Sudan Djibouti Sudan Pakistan

900 000 800 000 Number of microscopically confirmed cases 700 000 600 000 500 000 400 000 300 000 200 000 100 000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of microspically confirmed cases ITN IRS 1 800 000 1 600 000 1 400 000 1 200 000 1 000 000 800 000 600 000 400 000 200 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Aghanistan Djibouti Iran Irak Pakistan Saudi Arabia Somalia South Sudan Sudan Yemen

ACT

Aghanistan Djibouti Iran Irak Pakistan Saudi Arabia Somalia South Sudan Sudan Yemen

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

WORLD MALARIA REPORT 2013 | 83

European Region
Population aected: In 2000, eight countries in the European Region had ongoing transmission of malaria; however, in 2013, local transmission was conned to just three countries (Azerbaijan, Tajikistan and Turkey) in which 2.9 million people were living in areas with some risk for malaria (Figure A). All locally acquired cases are due to P. vivax (Figure B). Trends in cases and deaths: Among the 8 countries with ongoing transmission in 2000 the number of conrmed malaria cases decreased from 33 400 in 2000 to 235 in 2012. In 2012, 218 cases were from Turkey, while 16 locally acquired cases were reported from Tajikistan (13) and Azerbaijan (3). In addition, Georgia, which is in the prevention of reintroduction phase, reported one introduced case. The 218 cases in Turkey primarily originated from an outbreak in a village in the south-east, which appears to have arisen after importation by international truck drivers. Despite this outbreak, all countries in the region with ongoing transmission (Azerbaijan, Tajikistan and Turkey) achieved >75% decrease in case incidence between 2000 and 2012 (Figure D). Kyrgyzstan and Uzbekistan have recorded zero locally acquired cases since 2011, and as of 2013 they are classied as in the prevention of reintroduction phase . Greece, which had remained malaria free between 1974 and 2010, reported 3 locally acquired P. vivax cases in 2010, 40 in 2011 and 20 in 2012; these cases originated initially from migrant workers. Most of the cases were clustered in the prefecture of Lakonia in the south of mainland Greece. Following intensied control eorts, no locally acquired cases were reported from this area in 2013, but two locally acquired P. vivax local cases were detected in the Municipality of Alexandroupolis, Evros and one from the Municipality of Sofades, Karditsa. Links with antimalarial interventions: All countries in the region have high coverage of preventive interventions in malaria focal areas, with IRS and ITNs as appropriate, and they report adequate
A Population at risk, 2012
High risk (>1 per 1000)
Tajikistan

Countries in the elimination phase Azerbaijan Tajikistan Turkey

Countries in the prevention of re-introduction phase Georgia Countries certied malaria free Armenia, 2011 Turkmenistan, 2010 Kyrgyzstan Uzbekistan

access to antimalarial medicines (Figures G, H). Countries also benet from intensive surveillance, including case detection, investigation and quality assurance for laboratory diagnosis. Summary: Of the nine malaria aected countries with ongoing transmission in 2000, two have been certied free of malaria (Armenia in 2011 and Turkmenistan in 2010), one was added to the supplementary list1,2 (Russian Federation), and three have reported zero indigenous cases for the past 3 years or more, and are in the prevention of reintroduction phase (Georgia, Kyrgyzstan and Uzbekistan). The remaining three countries have each achieved >75% reduction in case incidence. The region is close to attaining the goal of eliminating malaria from the region by 2015, as set out in the 2005 Tashkent Declaration, which was endorsed by nine malaria-aected countries. Nonetheless, the experience of Greece and Turkey highlights the continual threat of reintroduction and the need for continued vigilance to ensure that any resurgence can be rapidly contained.
1. The supplementary list records countries where malaria has never existed or has disappeared without specic measures. 2. Kazakhstan, which was free of malaria in 2000, was also added to the supplementary list in 2012. B Percentage of cases due to P. falciparum and P. vivax, 20082012

Low risk (1 per 1000)

Malaria free
Turkey

P. falciparum

P. vivax

Other

Azerbaijan

Tajikistan

Georgia

Uzbekistan

Uzbekistan

Georgia

Kyrgyzstan

Azerbaijan

Turkey

Kyrgyzstan

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

84 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012

Turkey

D Percentage change in incidence of microscopically conrmed cases, 20002012

100%

Change in incidence rate due to all species Change in incidence rate due to P. vivax

Uzbekistan

50%
Kyrgyzstan

0%
Azerbaijan

-50%
Tajikistan

Uzbekistan

Tajikistan

Kyrgyzstan

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in incidence of microscopically conrmed cases by 2015
Georgia Azerbaijan Tajikistan Turkey Kyrgyzstan Uzbekistan

F Countries projected to achieve 75% decrease in incidence of microscopically cases by 2015 or with insuciently consistent data to assess trends
1 000 000

40 000

Number of microscopically confirmed cases

30 000

Number of microspically confirmed cases

100 000

20 000

10 000

10 000

1 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Azerbaijan

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Azerbaijan

IRS

Azerbaijan

Georgia

Turkey

Georgia

-100%

ACT

Georgia

Georgia

Kyrgyzstan

Kyrgyzstan

Tajikistan

Tajikistan

Turkey

Turkey

Uzbekistan

Uzbekistan

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

WORLD MALARIA REPORT 2013 | 85

South-East Asia Region

Populations aected: About 1.6 billion people are at some risk for malaria in the 10 malaria-endemic countries, and 1 billion people are at high risk (Figure A). Most cases in the region are due to P. falciparum, but in Nepal and Sri Lanka, most cases are due to P. vivax, and exclusively so in the Democratic Peoples Republic of Korea (Figure B). Trends in cases and deaths: The number of conrmed malaria cases reported in the region decreased from 2.9 to 2 million between 2000 and 2012. Three countries accounted for 96% of reported cases in 2012: India (52%), Myanmar (24%) and Indonesia (22%). Five countries achieved >75% decrease in case incidence between 2000 and 2012 (Bangladesh, Bhutan, Democratic Peoples Republic of Korea, Nepal, Sri Lanka) (Figure D). Thailand1 and Timor-Leste are projected to achieve >75% decrease by 2015. The number of reported cases in India decreased from 2 million in 2000 to 1.1 million in 2011, whereas the number of slides examined increased from 87 million to 109 million; the country is on track to achieve a 50%75% decrease in case incidence by 2015. It was not possible to discern the direction of trends in Indonesia and Myanmar, owing to changes in diagnostic testing or reporting over time (Figures D, F). Myanmar has seen large increases in the use of RDTs since 2007, whereas more reports have been received from eastern Indonesia (where malaria transmission is higher) since 2004. Reported malaria deaths in the region decreased from 5500 to 1200 between 2000 and 2012. Myanmar, India and Indonesia accounted for 49%, 42% and 33% of reported deaths respectively in 2012 (Annex 6D). The reported malaria mortality rate fell by more than >75% in Bangladesh, Bhutan, Sri Lanka, Thailand
1. Totals for Thailand in 2012 are inated compared to earlier years owing to the inclusion of data, for the rst time, from NGOs working in areas bordering Myanmar.

Countries in pre-elimination phase Bhutan Democratic Peoples Republic of Korea

Countries in the elimination phase Sri Lanka

and Timor-Leste2 between 2000 and 2012. The reported malaria mortality rate in Myanmar decreased by 79%, but this is partly due to a change in reporting practices because only conrmed malaria deaths have been reported since 2007. A decrease of 51% was observed in India. The number of reported deaths in Democratic Peoples Republic of Korea and Nepal is too small to make an assessment of trends, and gaps in reporting prevent an assessment of trends in malaria mortality in Indonesia. Links with antimalarial interventions: Five of the six countries with >75% decrease in case incidence had distributed sucient ITNs, or undertaken sucient IRS, to cover >50% of the population at high risk in 2012 (Figure G). All the countries except Indonesia reported delivering sucient antimalarial medicines to treat all patients attending public health facilities in 2012 (Figure H). Summary: Of the 10 countries with ongoing transmission in the region, ve have reduced malaria case incidence by >75%, while two countries are on track to achieve >75% decrease by 2015 and one a decrease of 50%75%. In the remaining two countries, progress is obscured by changes in diagnostic or reporting practices. Sri Lanka is in the elimination phase whereas Bhutan and Democratic Peoples Republic of Korea are in the pre-elimination phase.
2. In Timor-Leste the earliest that data are available is 2004.

A Population at risk, 2012

High risk (>1 per 1000)
Democratic Republic of Timor-Leste India Nepal Bhutan Indonesia Myanmar Thailand Democratic Peoples Republic of Korea Sri Lanka Bangladesh

B Percentage of cases due to P. falciparum and P. vivax, 20082012

Low risk (1 per 1000) Malaria free
Bangladesh Democratic Republic of Timor-Leste Myanmar Bhutan Indonesia India Thailand Nepal Sri Lanka Democratic Peoples Republic of Korea

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

86 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012 (average)

Sri Lanka Democratic Republic of Timor-Leste India Bhutan Thailand Myanmar Bangladesh

D Percentage change in incidence of microscopically conrmed cases, 20002012

100%

Change in incidence rate due to all species Change in incidence rate due to P. vivax

50%

0%

-50%
Indonesia Nepal Democratic Peoples Republic of Korea Nepal Bangladesh Indonesia India Democratic Republic of Timor-Leste Myanmar Sri Lanka Thailand Bhutan

-100%
Democratic Peoples Republic of Korea

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in incidence of microscopically conrmed cases by 2015
Sri Lanka Democratic Peoples Republic of Korea Thailand Bangladesh Democratic Republic of Timor-Leste Nepal Bhutan

F Countries projected to achieve 75% decrease in incidence of microscopically cases by 2015 or with insuciently consistent data to assess trends
India Indonesia Myanmar

500 000

3 000 000 2 500 000 Number of microspically confirmed cases 2 000 000 1 500 000 1 000 000 500 000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Number of microscopically confirmed cases

400 000

300 000

200 000

100 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Bangladesh Bhutan Democratic Peoples Republic of Korea Democratic Republic of Timor-Leste India Indonesia Myanmar Nepal Sri Lanka Thailand

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Bangladesh Bhutan Democratic Peoples Republic of Korea Democratic Republic of Timor-Leste India Indonesia Myanmar Nepal Sri Lanka Thailand

IRS

ACT

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

WORLD MALARIA REPORT 2013 | 87

Western Pacic Region

Populations aected: In the Western Pacic Region, 711 million people in 10 countries are at some risk for malaria, and 70 million people are at high risk (Figure A). Malaria transmission is intense in most of Papua New Guinea, Solomon Islands and Vanuatu. It is highly focal in the Greater Mekong subregion, including Cambodia, Yunnan province (China), the Lao Peoples Democratic Republic and Viet Nam (where it is most intense in remote forested areas, and disproportionately aects ethnic minorities and migrants. Malaria is also restricted in distribution in Malaysia, the Philippines and the Republic of Korea. Most countries have both P. falciparum and P. vivax, but cases are entirely due to P. vivax in the Republic of Korea and in central areas of China (Figure B). Trends in cases and deaths: The number of conrmed malaria cases reported between 2000 and 2012 decreased from 383 000 to 298 000. Three countries accounted for 79% of reported cases in 2012: Papua New Guinea (50%), the Lao Peoples Democratic Republic (15%) and Cambodia (14%). Eight countries (Cambodia, China, Malaysia, Philippines, Republic of Korea, Solomon Islands, Vanuatu and Viet Nam) achieved >75% decrease in the incidence of microscopically conrmed malaria cases between 2000 and 2012 (Figures D, E). The Lao Peoples Democratic Republic is projected to achieve a decrease of >75% by 2015, although it saw a twofold increase in malaria cases in 2012. This was primarily due to increased incidence in six southern provinces which associated with population movement related to economic development. Papua New Guinea reported an increase in conrmed cases in 2012 due to wide extension of diagnostic testing to health facilities that had not previously undertaken testing; otherwise it would have been on track to achieve a reduction in case incidence of more than 25% since 2000 (Figures D, F).

Country in pre-elimination phase Malaysia Country in elimination phase Republic of Korea

The number of reported malaria deaths in the region decreased from 2400 in 2000 to 460 in 2012. Three countries accounted for 86% of reported deaths in 2012: Papua New Guinea (66%), Cambodia (10%) and the Lao Peoples Democratic Republic (10%) (Annex 6D). Reported malaria mortality rates fell >75% in Cambodia, the Lao Peoples Democratic Republic, the Philippines and Solomon Islands, and by >50% in China, Malaysia and Papua New Guinea. The number of reported deaths in the Republic of Korea and Vanuatu was too small to make an assessment of trends. Links with antimalarial interventions: Eight countries had distributed sucient ITNs, or undertaken sucient IRS, to cover >50% of the population at high risk in 2012 (Figure G). All the countries in the region except China, Papua New Guinea and the Republic of Korea reported delivering sucient antimalarial medicines to treat all patients attending public health facilities in 2012 (Figure H). Summary: Of the 10 countries with ongoing transmission, eight have achieved >75% decrease in case incidence, while one country is projected to decrease malaria case incidence by 75% by 2015. Progress is slower in the country that accounts for the majority of cases and deaths in the region (Papua New Guinea).

A Population at risk, 2012

High risk (>1 per 1000)
Papua New Guinea Solomon Islands Vanuatu Philippines Lao Peoples Democratic Republic Cambodia China Viet Nam Republic of Korea Malaysia

B Percentage of cases due to P. falciparum and P. vivax, 20082012

Low risk (1 per 1000) Malaria free
Lao Peoples Democratic Republic Papua New Guinea Philippines Viet Nam Cambodia Solomon Islands Vanuatu Malaysia China Republic of Korea

P. falciparum

P. vivax

Other

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

88 | WORLD MALARIA REPORT 2013

C Annual blood examination rate, 20082012

Malaysia Solomon Islands Vanuatu Viet Nam Lao Peoples Democratic Republic Papua New Guinea Cambodia China Philippines Republic of Korea

D Percentage change in incidence of microscopically conrmed cases, 20002012

Change in incidence rate due to all species Change in incidence rate due to P. vivax

100%

50%
.

0%

-50%

0%

10%

20%

30%

40%

50%

E Countries projected to achieve >75% decrease in incidence of microscopically conrmed cases by 2015
Cambodia Solomon Islands Viet Nam Philippines Lao Peoples Democratic Republic China Malaysia Vanuatu Republic of Korea

F Countries projected to achieve 75% decrease in incidence of microscopically cases by 2015 or with insuciently consistent data to assess trends
Papua New Guinea

400 000

100 000

Number of microscopically confirmed cases

300 000

Number of microspically confirmed cases

80 000

60 000

200 000

40 000

100 000

20 000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Estimated percentage of high risk population protected with IRS or ITNs, 2012
ITN
Cambodia China Lao Peoples Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

H Percentage of cases potentially treated with antimalarial medicines, 2012

Any antimalarial
Cambodia China Lao Peoples Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

IRS

Lao Peoples Democratic Republic

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

Papua New Guinea

Philippines

Republic of Korea

Viet Nam

Solomon Islands

China

Malaysia

Cambodia

Vanuatu

-100%

ACT

100%

WORLD MALARIA REPORT 2013 | 89

References
1. Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IR, Johnston GL et al. A new world malaria map: Plasmodium falciparum endemicity in 2010. Malaria Journal, 2011, 10:378. 2. Gething PW, Elyazar IR, Moyes CL, Smith DL, Battle KE, Guerra CA et al. A long neglected world malaria map: Plasmodium vivax endemicity in 2010. PLoS Negl Trop Dis, 2012, 6(9):e1814 (http://www. ncbi.nlm.nih.gov/pubmed/22970336, accessed 20 November 2013). 3. Flaxman AD, Fullman N, Otten MW, Menon M, Cibulskis RE, Ng M et al. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assistance for health: A systematic synthesis of supply, distribution, and household survey data. PLoS Medicine, 2010, 7(8):e1000328. 4. Beiersmann C, Bountogo M, Tiendrebeogo J, De Allegri M, Louis VR, Coulibaly B et al. Falciparum malaria in young children of rural Burkina Faso: Comparison of survey data in 1999 with 2009. Malaria Journal, 2011, 10:296. 5. Landoh ED, Tchamdja P, Saka B, Tint KS, Gitta SN, Wasswa P et al. Morbidity and mortality due to malaria in Est Mono district, Togo, from 2005 to 2010: A times series analysis. Malaria Journal, 2012, 11:389. 6. Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ et al. Impact of mass distribution of free long-lasting insecticidal nets on childhood malaria morbidity: the Togo National Integrated Child Health Campaign. Malaria Journal, 2010, 9:199. 7. Bradley J, Matias A, Schwabe C, Vargas D, Monti F, Nseng G et al. Increased risks of malaria due to limited residual life of insecticide and outdoor biting versus protection by combined use of nets and indoor residual spraying on Bioko Island, Equatorial Guinea. Malaria Journal, 2012, 11:242. 8. Overgaard HJ, Reddy VP, Abaga S, Matias A, Reddy MR, Kulkarni V et al. Malaria transmission after ve years of vector control on Bioko Island, Equatorial Guinea. Parasit Vectors, 2012, 5:253. 9. Karema C, Aregawi MW, Rukundo A, Kabayiza A, Mulindahabi M, Fall IS et al. Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000 2010, Rwanda. Malaria Journal, 2012, 11:236. 10. Kalayjian BC, Malhotra I, Mungai P, Holding P, King CL. Marked decline in malaria prevalence among pregnant women and their ospring from 1996 to 2010 on the South Kenyan Coast. Am J Trop Med Hyg, 2013, (http://www.ncbi.nlm.nih.gov/ pubmed/24080635, accessed 20 November 2013). 11. Kigozi R, Baxi SM, Gasasira A, Sserwanga A, Kakeeto S, Nasr S et al. Indoor residual spraying of insecticide and malaria morbidity in a high transmission intensity area of Uganda. PLoS ONE, 2012, 7(8):e42857. 12. Mtove G, Amos B, Nadjm B, Hendriksen IC, Dondorp AM, Mwambuli A et al. Decreasing incidence of severe malaria and community-acquired bacteraemia among hospitalized children in Muheza, north-eastern Tanzania, 20062010. Malaria Journal, 2011, 10:320. 13. Okiro EA, Bitira D, Mbabazi G, Mpimbaza A, Alegana VA, Talisuna AO et al. Increasing malaria hospital admissions in Uganda between 1999 and 2009. BMC Medicine, 2011, 9:37.

90 | WORLD MALARIA REPORT 2013

Country proles
Afghanistan Algeria Angola Argentina Azerbaijan Bangladesh Belize Benin Bhutan Bolivia (Plurinational State of ) Botswana Brazil Burkina Faso Burundi Cambodia Cameroon Cabo Verde Central African Republic Chad China Colombia Comoros Congo Costa Rica Cte dIvoire Democratic Peoples Republic of Korea Democratic Republic of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Ethiopia French Guiana, France Gabon Gambia Ghana Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran (Islamic Republic of ) Kenya Kyrgyzstan Lao Peoples Democratic Republic 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 134 135 136 137 138 139 140 141 142 143 Liberia Madagascar Malawi Malaysia Mali Mauritania Mayotte Mexico Mozambique Myanmar Namibia Nepal Nicaragua Niger Nigeria Pakistan Panama Papua New Guinea Paraguay Peru Philippines Republic of Korea Rwanda Sao Tome and Principe Saudi Arabia Senegal Sierra Leone Solomon Islands Somalia South Africa Sri Lanka South Sudan Sudan Suriname Swaziland Tajikistan Thailand Democratic Republic of Timor-Leste Togo Turkey Uganda United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Uzbekistan Vanuatu Venezuela (Bolivarian Republic of ) Viet Nam Yemen Zambia Zimbabwe 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193

WORLD MALARIA REPORT 2013 | 91

C.1 Methods for preparing country proles

This section describes the methods used for preparing country proles. These methods also apply to other sections of the report.

C.1.2 Epidemiological prole

Population The total population of each country is taken from 2012 revision of the World population prospects (3). The country population is subdivided into three levels of malaria endemicity, as reported by the national malaria control programme (NMCP): 1 Areas of high transmission, where the reported incidence of conrmed malaria due to all species was >1 per 1000 population per year in 2012. 2 Areas of low transmission, where the reported malaria case incidence from all species was 1 per 1000 population per year in 2011, but >0. Transmission in these areas is generally highly seasonal, with or without epidemic peaks. 3 Malaria-free areas, where there is no continuing local mosquito-borne malaria transmission, and all reported malaria cases are imported. An area is designated malaria free when no cases have occurred for several years. Areas may be naturally malaria free due to altitude or other environmental factors that are unfavourable for malaria transmission, or they may become malaria free as a result of eective control eorts. In practice, malaria-free areas can be accurately designated by national programmes only after taking into account the local epidemiological situation and the results of entomological and biomarker investigations. If cases where a national programme did not provide the number of people living in high- and low-risk areas, the numbers were inferred from subnational case incidence data provided by the programme. The population at risk is the total population living in areas where malaria is endemic (low and high transmission), excluding the population living in malaria-free areas. The population at risk is used as the denominator in calculating the coverage of malaria interventions; hence, it is used in assessing current and future needs for malaria control interventions, taking into account the population already covered. For countries in the pre-elimination and elimination stages, population at risk is dened by the countries, based on the resident populations in foci where active malaria transmission occurs. Parasites and vectors The species of mosquito responsible for malaria transmission in a country, and the species of Plasmodium involved, are listed according to information provided by WHO regional oces. The proportion of malaria cases due to P. falciparum is estimated from the number of P. falciparum and mixed infections detected by microscopy, divided by the total number of microscopically conrmed malaria cases.

C.1.1 Maps
Conrmed cases per 1000 population The epidemiological maps for each country shown in the country proles are based on the number of conrmed cases per 1000 population in 2012 (the working denition of a case of malaria is considered to be fever with parasites). Incidence rates are corrected for reporting completeness by dividing by the proportion of health-facility reports received in 2012. Seven levels of endemicity are shown:

>100 cases per 1000 population per year 50 cases per 1000 population per year and <100 cases >10 cases per 1000 population per year but <50 cases >1 cases per 1000 population per year but <10 cases >0.1 cases per 1000 population per year but <1 cases >0 cases per 1000 population per year but <0.1 cases 0 recorded cases.

The rst four categories correspond to the high-transmission category dened below. Case incidence rates for 2012 do not necessarily reect the endemicity of areas in previous years. If subnational data on population or malaria cases were lacking, an administrative unit was labelled no data on the map. In some cases, the subnational data provided by a malaria control programme did not correspond to a mapping area known to WHO, either because of modications to administrative boundaries, or the use of names not veriable by WHO. The maps for countries in sub-Saharan Africa display a combination of: (i) cases per 1000 per year and, (ii) parasite prevalence in areas with >10 cases per 1000 population per year. To obtain a measure of combined parasite prevalence for both Plasmodium falciparum and P. vivax, the sum of the two independent parasite rates (1, 2) was calculated at each point (~5 km2). Data on environmental suitability for malaria transmission were used to identify areas that would be free of malaria. Proportion of cases due to P. falciparum This map is based on the proportion of P. falciparum in 2012: total number of cases due to P. falciparum divided by the total number of positive cases. Five levels of endemicity are shown:

80% P. falciparum 50% to <80% P. falciparum 10% to <50% P. falciparum >0% to <10% P. falciparum 0% cases due to P. falciparum.

C.1.3 Intervention policies and strategies

Intervention policy The policies and strategies adopted by each country for malaria prevention, diagnosis and treatment may vary according to the epidemiological setting, socioeconomic factors and the capacity

If no data are available for a subnational geographical area, or there is an insucient number of cases to calculate a reliable proportion, the area is highlighted as such.
92 | WORLD MALARIA REPORT 2013

of the NMCP or the countrys health system. Adoption of policies does not necessarily imply immediate implementation, nor does it indicate full, continuous implementation nationwide. Antimalarial treatment policy Antimalarial treatment policies are shown, together with the results of recent therapeutic ecacy tests (where these are available). Data on therapeutic ecacy were extracted from the WHO global database on antimalarial drug ecacy, and they originate from three main sources: published data, unpublished data and regular monitoring data from surveillance studies conducted according to the WHO standard protocol. The percentage of treatment failures is equal to the total number of failures (early treatment failures plus late clinical failures plus late parasitological failures), divided by the total number of patients who completed the study follow-up. The number of studies included in the analysis and the years during which the studies were conducted are shown for each antimalarial medicine. The minimum, median and maximum describe the range of treatment failures observed in the studies for each antimalarial medicine.

implementation are dicult to interpret nationwide (and are therefore not presented in the proles), but they can be useful for assessing progress locally. Many of these surveys are conducted during the dry season (for logistic reasons), and actual rates of ITN use of nets may be higher during the time of peak malaria transmission.

Proportion of population with access to an ITN within their household an indicator to measure the proportion of households that have a sucient number of ITNs to cover all individuals who spent the previous night in surveyed households, assuming each ITN is shared by two people. This is labelled as With access to an ITN in household in the graphs. Proportion of population who slept under an ITN the previous night an indicator to provide a direct measure of ITN use by all age groups at the time a survey is conducted. It is labelled as All ages who slept under an ITN in the graphs.

Modelled estimates For high-burden countries in the African Region, a model was used to estimate the proportion of the population with access to an ITN within their household for years in which household survey results are not available. The model takes into account data from three sources: household surveys, the number of ITNs delivered by manufacturers to a country, and the number of ITNs distributed by NMCPs (Section 4.1) (4). For years in which survey results are available, the estimates of the model are close to those of the survey. For years in which household survey results are not available, the model uses data on ITNs procured from manufacturers and distributed by NMCPs, to estimate the change in coverage between survey years.

C.1.4 Financing
Sources of nancing The data shown are those reported by the programme. The rst graph shows nancial contributions by source or name of agency, by year. The government contribution is usually the declared government expenditure for the year. In cases where government expenditure was not reported by the programme, the government budget was used. External contributions are contributions allocated to the programme by external agencies, but these may or may not be disbursed. Additional information about contributions from specic donor agencies, as reported by these agencies, is given in Annex 2. All countries were asked to convert their local currencies to US$. Expenditure by intervention in 2012 The pie chart shows the proportion of malaria funding from all sources that was spent on the following activities in 2012: insecticide-treated nets (ITNs), insecticides and spraying materials, indoor residual spraying (IRS), diagnosis, antimalarial medicines, monitoring and evaluation, human resources, technical assistance and management. There may be dierences in the completeness of data, and the listed expenditures on activities may not include all items of expenditure. For example, government expenditures usually only include expenditures specic to malaria control, but do not take into account costs related to maintaining health systems, human resources and so on.

Programme data: For countries in WHO regions other than the African Region, nationally representative surveys are usually not undertaken frequently enough to allow assessment of trends in intervention coverage or to provide contemporary information. Therefore, ITN coverage is estimated using data on the number of ITNs distributed by malaria programmes. The information is used to estimate the proportion of the population potentially protected with ITNs, as described below. Proportion of population potentially protected with ITNs calculated as the number of ITNs distributed multiplied by 1.8 (a ratio of one ITN for every two persons, but allowing for only one person sleeping under some ITNs in households with an odd number of inhabitants) divided by the population at high risk. This is labelled as At high risk protected with ITNs in the graphs.

C.1.5 Coverage
Coverage of ITNs and IRS Household surveys The percentage of the population with access to an ITN in their household and the percentage of people who sleep under an ITN are taken from nationally representative household surveys, such as multiple indicator cluster surveys (MICS), demographic and health surveys (DHS), and malaria indicator surveys (MIS). Other available national surveys were also included. The results of subnational surveys undertaken to support local project

Long-lasting insecticidal nets (LLINs) are considered to have an average useful lifespan of 3 years; hence, the cumulative total of mosquito nets distributed over the past consecutive 3 years is taken as the number of ITNs available for any particular year. Other ITNs are considered to have an average lifespan of 1 year, but some nets will be eective for longer if re-treated with insecticide. Therefore, the numerator for LLINs and ITNs is the sum of the cumulative LLINs distributed in the most recent 3 years, plus the number of ITNs distributed and re-treated during the most recent year. Outside Africa, the population at high risk is used as the denominator for vector control coverage; this is because the
WORLD MALARIA REPORT 2013 | 93

population at low risk is often at very low risk, and it is not clear whether ITNs or IRS are needed by the entire population. Programme data are also used to calculate the following indicator:

delivered, divided by the number of estimated P. falciparum malaria cases in the public sector, multiplied by 100. These indicators can provide information on whether the malaria control programme delivers sucient antimalarial medicines to treat all malaria patients who seek treatment in the public sector. For high-transmission countries in the African Region, the estimated number of cases attending public sector health facilities is used as a denominator. For other countries, the denominator is the number of conrmed cases plus the number of presumed cases, adjusted for reporting completeness.

Proportion of the population at risk protected by IRS calculated as the number of people living in a household where IRS has been applied during the preceding 12 months, divided by the population at risk (the sum of populations living in low- and high-transmission areas), multiplied by 100. For areas outside Africa, the population at high risk is used as the denominator.

Programme data are the most important source of information for estimating IRS coverage, because household surveys do not generally include questions on IRS. In addition, IRS is often carried out on a limited geographical scale, and nationally representative household surveys may not provide an adequate sample size within targeted areas to allow coverage to be measured accurately. The percentage of people protected by IRS is a measure of the extent to which IRS is implemented and the extent to which the population at risk benets from IRS nationwide. The data show neither the quality of spraying nor the geographical distribution of IRS coverage in a country. Cases tested and artemisinin-based combination therapy (ACT) delivered The following indicator on access to diagnostic testing is calculated:

C.1.6 Impact
Malaria test positivity rate and annual blood examination rate The following indicators are presented to help interpret observed trends:

Annual blood examination rate (ABER) the number of parasitological tests (by microscopy or RDT) undertaken per 100 people at risk per year. Slide positivity rate (SPR) the number of microscopically positive cases divided by the total number of slides examined, multiplied by 100. RDT positivity rate the number of positive RDT tests divided by the total number of RDT tests carried out, multiplied by 100.

The proportion of suspected cases attending public health facilities that receive a diagnostic test the number of suspected cases examined by microscopy or by rapid diagnostic test (RDT), divided by the total number of suspected malaria cases, multiplied by 100. This indicator reects the extent to which a programme can provide diagnostic services to patients attending public health facilities. It does not consider patients attending privately run health facilities, and therefore does not reect the experience of all patients seeking treatment. In many situations, health facilities in the private sector are less likely to provide a diagnostic test than those in the public sector. The indicator may also be biased if those health facilities that provide a diagnostic test (e.g. hospitals) are more likely than others to submit monthly reports.

The ABER provides information on the extent of diagnostic testing in a population, and completeness of reporting of health facilities, and is useful to take into account when interpreting trends in conrmed cases (see Section A.1.6). To discern decreases in malaria incidence, the ABER should ideally remain constant or be increased. RDT and SPRs are derived from the number of parasitologically positive cases per 100 cases examined by RDT or microscopy. They measure the prevalence of malaria parasites among people who seek care and are examined in health facilities. Trends in these indicators may be less distorted by variations in the ABER than trends in the number of conrmed cases. Proportion of cases due to P. vivax

Few countries have information systems that are able to record the treatments given to individual patients. Instead, programme data on the numbers of antimalarial medicines distributed by the programmes are used to calculate proxy indicators for access to treatment. Three indicators are calculated:

Proportion of cases due to P. vivax The total number of cases due to P. vivax, divided by the total number of positive cases.

Conrmed cases, admissions and deaths Where available, the numbers of conrmed malaria cases, admissions and deaths are shown, to provide information on trends in malaria. The numbers of conrmed cases, admissions and deaths are derived from case reports divided by the population at risk, multiplied by 100 000. These indicators are useful in assessing changes in the incidence of malaria over the years, provided that there has been consistency in case reporting over time. The numbers of cases, admissions and deaths due to P. vivax among total conrmed cases are also presented; these are useful in assessing changes in in the incidence of this parasite over time. For countries in the pre-elimination or elimination phases, the total number of indigenous cases (acquired within the country) and imported cases are also plotted.

Proportion of malaria cases potentially treated with any antimalarial in the public sector the number of antimalarial treatment courses delivered, divided by the number of estimated malaria cases in public health facilities, multiplied by 100. Proportion of P. falciparum malaria cases potentially treated with ACT in the public sector the number of ACT courses delivered, divided by the number of estimated P. falciparum malaria cases in the public sector, multiplied by 100.

Proportion of P. vivax malaria cases potentially treated with primaquine in the public sector the number of ACT courses
94 | WORLD MALARIA REPORT 2013

C.1.7 Assessing trends in the incidence of malaria

Assessing whether data are suciently reliable to assess trends in case incidence The reported numbers of malaria cases and deaths are used as core indicators for tracking the progress of malaria control programmes (5). The main sources of information on these indicators are the disease surveillance systems operated by ministries of health. Data from such systems have three strengths: (i) case reports are recorded continuously over time and can thus reect changes in the implementation of interventions or other factors; (ii) routine case and death reports are often available for all geographical units of a country; and (iii) the data reect the burden that malaria places on the health system. Changes in the numbers of cases and deaths reported by countries do not, however, necessarily reect changes in the incidence of disease in the general population, because (i) not all health facilities report each month, and so variations in case numbers may reect uctuations in the number of health facilities reporting rather than a change in underlying disease incidence; (ii) routine reporting systems often do not include patients attending private clinics or morbidity treated at home, so disease trends in health facilities may not reect trends in the entire community; and (iii) not all malaria cases reported are conrmed by microscopy or RDT, so that some of the cases reported as malaria may actually be other febrile illnesses (5, 6). When reviewing data supplied by ministries of health in malaria-endemic countries, the following strategy was used to minimize the inuence of these sources of error and bias:

Focusing on conrmed cases (by microscopy or RDT) to ensure that malaria (not other febrile illnesses) is tracked. For high-burden countries in the African Region, where there is little conrmation of cases, the numbers of malaria admissions (inpatient cases) and deaths are reviewed, because the predictive value of diagnosis undertaken for an admitted patient is considered to be higher than that of an outpatient diagnosis based only on clinical signs and symptoms. In such countries, the analysis may be heavily inuenced by trends in severe malaria rather than trends in all cases. Monitoring the number of laboratory tests undertaken. It is useful to measure the ABER, to ensure that potential dierences in diagnostic eort or completeness of reporting are taken into account. To discern decreases in malaria incidence, the ABER should ideally remain constant or be increased.1 In countries progressively reducing their malaria endemicity, the population at risk also reduces, becoming limited to active and residual foci where malaria transmission is present, or where there is potentially a high risk due to receptivity. In addition, it is useful to monitor the percentage of suspected malaria cases that were examined with a parasite-based test. When reviewing the number of malaria admissions and deaths, the

health-facility reporting rate (the proportion of health facilities that report) should remain constant and should be high (i.e. >80%). Monitoring trends in the SPR or RDT positivity rate. This rate should be less severely distorted by variations in the ABER than trends in the number of conrmed cases. Monitoring malaria admissions and deaths. For high-burden African countries, when the number of malaria admissions or deaths is being reviewed, it is also informative to examine the percentage of admissions or deaths due to malaria, because this proportion is less sensitive to variation in reporting rates than the number of malaria admissions or deaths. Monitoring the number of cases detected in the surveillance system in relation to the total number of cases estimated to occur in a country.2 Trends derived from countries with high case detection rates are more likely to reect trends in the broader community. When examining trends in the number of deaths, it is useful to compare the total number of deaths occurring in health facilities with the total number of deaths estimated to occur in the country. Examining the consistency of trends. Unusual variation in the number of cases or deaths, which cannot be explained by climate or other factors, or inconsistency between trends in cases and in deaths, can suggest deciencies in reporting systems. Monitoring changes in the proportion of cases due to P. falciparum or the proportion of cases occurring in children <5 years of age. Decreases in the incidence of P. falciparum malaria may precede decreases in P. vivax malaria, and there may be a gradual shift in the proportion of cases occurring in children <5 years; however, unusual uctuations in these proportions may point to changes in health-facility reporting or to errors in recording.

The aim of these procedures is to rule out data-related factors (e.g. incomplete reporting, or changes in diagnostic practice) as explanations for a change in the incidence of disease, and to ensure that trends in health-facility data reect changes in the wider community. The conclusion that trends inferred from health-facility data reect changes in the community has more weight if (i) the changes in disease incidence are large; (ii) coverage with public health services is high; and (iii) interventions promoting change, such as use of ITNs, are delivered throughout the community rather than being restricted to health facilities. Establishing a link between malaria disease trends and control activities In attempting to establish a causal link between malaria disease trends and control activities, one should consider what the disease trends would have been without application of the control activities, and then assess whether the decrease in malaria observed is greater than that expected without control activities (i.e. counterfactual). A realistic view of what would
2 The total number of malaria cases in a country can be estimated from the number of reported cases, taking into account variations in health-facility reporting rates, care-seeking behaviour for fever as recorded in household surveys, and the extent to which suspected cases are examined with laboratory tests (1). WORLD MALARIA REPORT 2013 | 95

1 Some authorities recommend that the ABER should exceed 10%, to ensure that all febrile cases are examined; however, the observed rate depends partly on how the population at risk is estimated, and trends may still be valid if the rate is <10%. Some authorities have noted that a value of 10% may not be sucient to detect all febrile cases. It is noteworthy that the ABER in the Solomon Islands, a highly endemic country, exceeds 60%, with an SPR of 25%, achieved solely through passive case detection.

have happened without control activities cannot be established from the data currently available to WHO. However, it can be expected that,without a change in control activities, malaria incidence might uctuate in response to short-term climate variations, but would otherwise be unlikely to change markedly, because factors such as improved living conditions, environmental degradation or long-term climate change have only gradual eects (although there may be local exceptions). Thus, a plausible link with control eorts can be established if the disease incidence decreases at the same time as control activities increase; if the magnitude of the decrease in malaria incidence is consistent with the magnitude of the increase in control activities (a 50% decrease in the number of cases is unlikely to occur if malaria control activities cover only 10% of the population at risk); and if the decreases in malaria incidence cannot readily be explained by other factors.

those obtained from nationally representative household surveys on health service use. If data from more than one household survey was available for a country, estimates of health service use for intervening years were imputed by linear regression. If only one household survey was available then health service use was assumed to remain constant over time; analysis summarized in the World Malaria Report 2008 indicated that the percentage of fever cases seeking treatment in public sector facilities varies little over time in countries with multiple surveys. Such a procedure results in an estimate with wide uncertainty intervals around the point estimate. (ii) Other countries in the WHO African Region. For some African countries the quality of surveillance data did not permit a convincing estimate to be made from the number of reported cases. For these countries, an estimate of the number of malaria cases was derived from an estimate of the number of people living at high, low or no risk of malaria. Malaria incidence rates for these populations are inferred from longitudinal studies of malaria incidence recorded in the published literature. Incidence rates are adjusted downward for populations living in urban settings and the expected impact of ITN and IRS programmes. The procedure was initially developed by the RBM Monitoring and Evaluation Reference Group in 2004 (9) and also described in World Malaria Report 2008. Deaths The number of malaria deaths was estimated by one of two methods: (i) Countries outside the WHO African Region and for low transmission countries in Africa4. The number of deaths was estimated by multiplying the estimated number of P. falciparum malaria cases by a xed case fatality rate for each country as described in the World Malaria Report 2008 (8). This method is used for all countries outside the African Region and for countries within the African Region where estimates of case incidence were derived from routine reporting systems and where malaria causes less than 5% of all deaths in children under 5 as described in the Global Burden of Disease 2004 update (10). A case fatality rate of 0.45% is applied to the estimated number of P. falciparum cases for countries in the African Region and a case fatality rate of 0.3% for P. falciparum cases in other Regions. In situations where the fraction of all deaths due to malaria is small, the use of a case fatality rate in conjunction with estimates of case incidence was considered to provide a better guide to the levels of malaria mortality than attempts to estimate the fraction of deaths due to malaria. (ii) Other countries in the WHO African Region, and South Sudan in the Eastern Mediterranean Region. Child malaria deaths were estimated using a verbal autopsy multi-cause model (VAMCM) developed by the WHO Child Health Epidemiology Reference Group (CHERG) to estimate causes of death for children aged 159 months in countries with less than 80% of vital registration coverage (11, 12, 13). The model was updated to include community-based verbal autopsy (VA) studies published between June
4 Botswana, Cabo Verde, Eritrea, Madagascar, Namibia, Swaziland, South Africa, and Zimbabwe

C.1.8 Classication of countries according to malaria programme phase

The criteria used to classify countries according to programme phase were updated in 2012 to facilitate tracking of progress over time (7). The updated criteria are based on an evaluation of three main components: the malaria epidemiological situation, case-management practices, and the state of the surveillance system (as shown in Table A.1).3 The evaluation concentrates on the situation in those districts of the country reporting the highest annual parasite index (API).

C.1.9 Estimates of malaria cases and deaths 20002012

Surveillance systems do not capture all malaria cases occurring in a country, and the data reported to WHO are not suciently reliable to assess trends in some countries. It is therefore necessary to use estimates of the total number of cases or deaths for some analysis included in country proles and elsewhere in the report. The methods for producing estimates either (i) adjust the number of reported cases to take into account the proportion of cases that are not captured by a surveillance system, or (ii) for countries with insucient surveillance data, produce estimates using a modeled relationship between malaria transmission, case incidence or mortality and intervention vector control coverage: Cases The number of malaria cases was estimated by one of two methods. (i) Countries outside the WHO African Region and low transmission countries in Africa: Estimates of the number of cases were made by adjusting the number of reported malaria cases for completeness of reporting, the likelihood that cases are parasite-positive and the extent of health service use. The procedure, which is described in the World Malaria Report 2008 (6, 8), combines data reported by NMCPs (reported cases, reporting completeness, likelihood that cases are parasite positive) with
3 Other components, such as (i) the stated programme goal; (ii) vector control and malaria prevention practices; and (iii) health systems and nancing, are also important for tracking progress towards elimination; however, they are less specic and therefore not included as classication criteria. 96 | WORLD MALARIA REPORT 2013

2, 2010 and May 27, 2013, as well as national VA surveys. A total of 128 data points from 95 VA studies and 37 countries that met the inclusion criteria5 were included. Among them 47 data points were either new or updated from the previous estimates of malaria deaths published in World Malaria Report 2012 (7) and World Malaria Report 2012. Mortality estimates for seven causes of post-neonatal death were derived, including pneumonia, diarrhoea, malaria, meningitis, injuries, congenital malformations, causes arising in the perinatal period (prematurity, birth asphyxia and trauma, sepsis and other conditions of the newborn), and other causes. Malnutrition deaths were included in the other cause of death category. Deaths due to measles, unknown causes, and HIV/AIDS are estimated separately. The resulting cause-specic estimates were adjusted country-bycountry to t the estimated 1-59 month mortality envelopes (excluding HIV and measles deaths) for corresponding years and then estimates were further adjusted for intervention coverage (pneumonia and meningitis estimates adjusted for the use of Haemophilus inuenzae type b vaccine; malaria estimates were adjusted for the use of insecticide treated mosquito nets (ITNs)). The bootstrap method was employed to estimate uncertainty intervals by re-sampling from the study-level data to estimate the distribution of the predicted percentage of deaths due to each cause. Deaths above ve years were inferred from a relationship between levels of malaria mortality in dierent age groups and the intensity of malaria transmission as described by Ross et al (14); thus the estimated malaria mortality rate in children under 5 years ve was used to infer malaria- specic mortality in older age groups.

5 Cibulskis RE, Bell D, Christophel EM, Hii J, Delacollette C, Bakyaita N et al. Estimating trends in the burden of malaria at country level. Am J Trop Med Hyg, 2007, 77(6 Suppl):133-137 (http://www.ncbi.nlm.nih.gov/pubmed/18165485, accessed. 6 Cibulskis RE, Aregawi M, Williams R, Otten M, Dye C. Worldwide incidence of malaria in 2009: estimates, time trends, and a critique of methods. PLoS Med, 2011, 8(12):e1001142 (http:// www.ncbi.nlm.nih.gov/pubmed/22205883, accessed. 7 World Malaria Report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/malaria/publications/world_malaria_report_2012/en/index.html, accessed 15 October 2013). 8 World Malaria Report 2008. Geneva, World Organization, 2008 (WHO/HTM/GMP/2008.1). Health

9 Korenromp E. Malaria incidence estimates at country level for the year 2004. Geneva, World Health Organization, 2005 (draft) (www.malariaconsortium.org/resources.php?action= download&id=177). 10 Global burden of disease: 2004 update. Geneva, World Health Organization, 2008 (http://www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/index.html). 11 Liu L et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, 2012, Lancet 2012, 379: 21512161. 12 Black RE et al. Global, regional and national causes of child mortality, 2008, Lancet 2010, 375: 19691987. 13 Johnson H et al. Estimating the distribution of causes of child deaths in high mortality countries with incomplete death certication. International Journal of Epidemiology, 2010, 39:11031114. 14 Ross A, Maire N, Molineaux L, Smith T. An epidemiologic model of severe morbidity and mortality caused by plasmodium falciparum. Am. J. Trop. Med. Hyg., 75(Suppl 2), 2006, pp. 6373

References
1 Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IR, Johnston GL et al. A new world malaria map: Plasmodium falciparum endemicity in 2010. Malaria Journal, 2011, 10:378. 2 Gething PW, Elyazar IR, Moyes CL, Smith DL, Battle KE, Guerra CA et al. A long neglected world malaria map: Plasmodium vivax endemicity in 2010. PLoS Negl Trop Dis, 2012, 6(9):e1814 (http://www.ncbi.nlm.nih.gov/pubmed/22970336, accessed 20 November 2013). 3 World population prospects. New York, United Nations (UN), UN Population Division, 2012 (http://esa.un.org/wpp/, accessed 24 November 2013). 4 Flaxman AD, Fullman N, Otten MW, Menon M, Cibulskis RE, Ng M et al. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assistance for health: A systematic synthesis of supply, distribution, and household survey data. PLoS Med, 2010, 7(8):e1000328.

5 Studies that were conducted in year 1980 or later, a multiple of 12 months in study duration, cause of death available for more than a single cause, with at least 25 deaths in children <5 years of age, each death represented once, and less than 25% of deaths due to unknown causes were included. Studies conducted in sub-groups of the study population (e.g. intervention groups in clinical trials) and verbal autopsy studies conducted without use of a standardized questionnaire or the methods could not be conrmed were excluded from the analysis. WORLD MALARIA REPORT 2013 | 97

Table A.1 Criteria for classifying countries according to malaria programme phase
Pre-elimination Elimination Prevention of reintroduction

Malaria situation in areas with most intense transmission

(1) Recently endemic country with zero local transmission for at least 3 years; or (2) country on the register or supplementary list that has ongoing local transmissiona <5% among suspected malaria patients (PCD) throughout the year <5 (i.e. fewer than 5 cases/1000 population) <1 (i.e. fewer than 1 case/1000 population)

Test positivity rate API in the district with the highest number of cases/1000population/ year (ACD and PCD),b averaged over the past 2 years Total number of reported malaria cases nationwide Case management

A manageable number, (e.g. <1000 cases, local and imported) nationwide Imported malaria. Maintain capacity to detect malaria infection and manage clinical disease National policy being rolled out Yes Yes

All cases detected in the private sector are microscopically conrmed All cases detected in the public sector are microscopically conrmed Nationwide microscopy quality assurance system covers public and private sector Radical treatment with primaquine for P. vivax Treatment with ACT plus singledose primaquine for P. falciparum Surveillance Malaria is a notiable disease nationwide (< 2448 hours) Centralized register on cases, foci and vectors Malaria elimination database Active case detection in groups at high risk or with poor access to services (proactive case detection) Case and foci investigation and classication (including reactive case detection and entomological investigation)

National policy being rolled out

Yes

Yes

Initiated

Yes

Yes

National policy being updated National policy being updated

National policy fully implemented National policy fully implemented

Yes Yes Vigilance by the general health services

Laws and systems being put in place Initiated Initiated Initiated

Yes Yes Yes Yes

Yes Yes Certication process (optional) In residual and cleared-up foci, among high-risk population groups Yes

Initiated

Yes

ABER, annual blood examination rate; ACD, active case detection; API, annual parasite index; PCD, passive case detection a) Ongoing local transmission = 2 consecutive years of local P. falciparum malaria transmission, or 3 consecutive years of local P.vivax malaria transmission, in the same locality or otherwise epidemiologically linked. b) The API has to be evaluated against the diagnostic activity in the risk area (measured as the ABER). Low values of ABER in a district raise the possibility that more cases would be found with improved diagnostic eorts.

98 | WORLD MALARIA REPORT 2013

Afghanistan
Conrmed cases per 1000 population Insufficient data 0

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2011 reported data

00.1 0.11.0 1.010 1050 50100 100

Based on 2011 reported data

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
7 960 000 15 100 000 6 730 000 29 790 000

%
27 51 23

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (2%), P. vivax (98%) An. stephensi, superpictus, hyrcanus, pulcherrimus, culicifacies, uviatilis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes No Yes Yes No No 2005 2010 2012 2000 2003 2003 2010 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
CQ AS+SP QN AM+QN CQ+PQ(8w)

Year adopted
2004 P.f only, PAN-only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20052012

Min
0

Median
0

Max
3.8

Follow-up No. of studies Species

28 days 8 P. f

III. Financing
12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004
Source: MIS 2009, MIS 2011

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

20 16 12 8 4 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

6 000 5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths

50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 99

Deaths

Algeria
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
1 22 800 000 37 800 000 60 600 000

%
38 62

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (81%), P. vivax (19%) An.labranchiae, multicolor, sergentii, hispaniola

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No Yes Yes Yes Yes No Yes No 1980 1968

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No No Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
CQ

Year adopted
0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax potentially treated with primaquine

V. Impact
10 Positivity rate (%) 8 6 4 2 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

1 000 Confirmed cases 600 400 200 0 2000 2001 2002 2003 2004

RDT positivity rate

Slide positivity rate

70 60 50 40 30 20 10 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases 800

Indigenous malaria cases by species

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: Increase in incidence 20002012

100 | WORLD MALARIA REPORT 2013

Angola
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
20 800 000 0 0 20 800 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes 2001 2010 2010 2010 2014 2006 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
QN

Year adopted
2006 2006 2006 2006

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, PMI/ USAID, Other Bilaterals

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: MIS 2007, MIS2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

18 16 14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

300 250 200 150 100 50 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 101

Deaths

Argentina
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
0 41 100 000 41 100 000

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An.pseudopunctipennis, darlingi

100

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No No N/A Yes Yes Yes Yes No Yes Yes 1980

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No Yes Yes No Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
AL CQ+PQ

Year adopted

0.25 mg/kg (14 days) Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median

III. Financing
3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

5 4 3 2 1 0 2012 ABER (%) Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

500 400 300 200 100 0

RDT positivity rate

Slide positivity rate

500 400 300 200 100 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

102 | WORLD MALARIA REPORT 2013

Azerbaijan
Conrmed cases per 1000 population Insufficient data 0

European Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
6 11 800 9 200 000 9 211 800

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (100%) An.arabiensis, sergentii, funestus, bacroftii, albimanus, balabacensis

100

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes N/A Yes Yes No Yes No Yes Yes 2009 1930 1930 1930 2009 1956 1956 1956

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No Yes Yes Yes Yes 1930 1930 1998 1930 1930

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

AS+SP QN+CL AS; QN CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

300 250 200 150 100 50 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
0.5 Positivity rate (%) 0.4 0.3 0.2 0.1 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

1 800 1 500 1 200 900 600 300 0

RDT positivity rate

Slide positivity rate

1 800 1 500 1 200 900 600 300 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 103

Bangladesh
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 110 000 11 900 000 139 000 000 155 010 000

%
3 8 90

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (91%), P. vivax (9%) An. dirus, minimus, philippinensis, sundaicus, albimanus, annularis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes No Yes No No Yes 2008 2008 2008 2008 2008 2008 2008 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No 2008 2008

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

AS+ 2004 2004 2004 AM; QN 2004 CQ+PQ(14d) 0.25 mg/kg (14 days) P.f only, PAN-only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL QN-D

Year
20062010 20082009

Min
0 0

Median
0 0

Max
2 0

Follow-up No. of studies Species

28 days 42 days 7 1 P. f P. f

III. Financing
20 16 12 8 6 4 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

6 000 5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths

700 600 500 400 300 200 100 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

104 | WORLD MALARIA REPORT 2013

Deaths

Belize
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
0 224 000 100 000 324 000

%
0 69 31

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (3%), P. vivax (97%) An. albimanus, darlingi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes No Yes No Yes No 2009 2009 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

CQ+PQ QN CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

16 14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

7 6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

18 16 14 12 10 8 6 4 2 0 2000 Cases per 1000

Malaria admissions and deaths

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 105

Deaths

Benin
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
10 100 000 0 0 10 100 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, melas

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes Yes Yes No Yes No No No Yes 2007 2006 2005 2011 2008 2008 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
QN

Year adopted
2004 2004 2004 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052009

Min
0

Median
0.75

Max
6.5

Follow-up No. of studies Species

28 days 4 P. f

III. Financing
45 40 35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2006

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

900 800 700 600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

106 | WORLD MALARIA REPORT 2013

Deaths

Bhutan
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
518 000 729 000 1 247 000

%
42 58

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (43%), P. vivax (57%) An.maculatus, culicifacies, philippiensis, annularis

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes No No Yes 2006 2006 1964 1964 1964 2006 2012

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

No No Yes Yes No Yes Yes 2011 2012 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

N2006 2006 2006 AM; QN 2006 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052011

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 23 P. f

III. Financing
2.0 1.6 1.2 0.8 0.4 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

20 16 12 8 4 0 2012 ABER (%) Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
10 Positivity rate (%) 8 6 4 2 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

7 000 6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

7 000 6 000 5 000 4 000 3 000 2 000 1 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 107

Bolivia (Plurinational State of )

Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
504 000 3 200 000 6 790 000 10 494 000

%
5 30 65

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (5%), P. vivax (95%) An. darlingi, pseudopunctipennis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes No No Yes No No No 2008 2005 1959 2000 1996 2003 1998

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No Yes No No 1998

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+MQ+PQ QN+CL QN CQ+PQ(14d)

Year adopted

2001 2001 2001 0.5 mg/kg (7 days) P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

35 000 30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
300 250 200 150 100 50 0 2000

Malaria admissions and deaths

12 10 8 6 4 2 0

Admissions

Total cases

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

108 | WORLD MALARIA REPORT 2013

Deaths

Botswana
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
361 000 942 000 701 000 2 004 000

%
18 47 35

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No No No Yes 2009 1997 1950 1950 2010 1995 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No 2012 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2007 2007 2007 2007

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
2.0 Contribution (US$m) 1.5 1.0 0.5 0 2000 2001 2002 2003 2004

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

2.5 Cases due to P. vivax (%) ABER (%) 2.0 1.5 1.0

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

0 2012

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths

45 40 35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 109

Deaths

Brazil
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 570 000 35 800 000 158 000 000 198 370 000

%
2 18 80

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (15%), P. vivax (85%) An. darlingi, albitarsis, aquasalis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes Yes Yes No No No 2007 2007 1945 1972 1972 2006 2010 2011 1972

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2012 AL+PQ(1d); AS+MQ+PQ(1d) AM+CL; AS+CL 2006 CQ+PQ(7d);CQ+PQ(14d) 0.5 mg/kg (7 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+MQ AL

Year
20052007 20052007

Min
0 0

Median
0 0

Max
0 0

Follow-up No. of studies Species

42 days 28 days 3 2 P. f P. f

III. Financing
120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 2000 Total cases per 1000

Malaria admissions and deaths

250 200 150 100 50 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

110 | WORLD MALARIA REPORT 2013

Deaths

Burkina Faso
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
16 500 000 0 0 16 500 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes Yes No Yes No No No No Yes 2007 1998 2006 2012 2005 2009 2009 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; AS+AQ AL; AS+AQ QN QN

Year adopted
2005 2005 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL AS+AQ

Year
20052009 20062009

Min
1.9 3.2

Median
7 15.3

Max
12.5 21.5

Follow-up No. of studies Species

28 days 28 days 6 3 P. f P. f

III. Financing
80 70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2003, MICS 2006, DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

250 200 150 100 50 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 111

Deaths

Burundi
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
2 360 000 5 320 000 2 170 000 9 850 000

%
24 54 22

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes No Yes No No No No No No 2004 2009 2012 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2003 2003 2003 2003

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20052006

Min
2.9

Median
5.2

Max
7.5

Follow-up No. of studies Species

28 days 2 P. f

III. III.Financing Financing

25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. IV.Coverage Coverage

100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. V.Impact Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

250 200 150 100 50 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1600 Admissions 1200 800 400 0 2000 2001 2002 2003 Cases per 1000

Malaria admissions and deaths (100 000)

35 30 25 20 15 10 5 0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

112 | WORLD MALARIA REPORT 2013

Deaths

Cambodia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 540 000 1 340 000 6 990 000 14 870 000

%
44 9 47

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (56%), P. vivax (44%) An. dirus, minimus, maculatus, sundaicus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No No N/A Yes Yes Yes Yes No No Yes No Yes 2000 2000 2000 2000 2000 2000 2012 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+MQ; DHA-PPQ+PQ QN+T AM; QN DHA-PPQ

Year adopted

P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

DHA-PPQ DHA-PPQ

Year
20082013 20102011

Min
0 0

Median
3.6 0

Max
30.8 0

Follow-up No. of studies Species

42 days 28 days 15 3 P. f P. v

III. Financing
50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

7 6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

18 000 16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 2000 Cases per 1000

Malaria admissions and deaths

700 600 500 400 300 200 100 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 113

Deaths

Cameroon
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
15 400 000 6 290 000 0 21 690 000

%
71 29 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, funestus, moucheti, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No No N/A Yes Yes No Yes No No Yes 2007 2004 2011 2012 2006 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN AM; QN

Year adopted
2004 2004 2004 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2004, MICS 2006

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

5.90 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
Positivity rate (%)

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

5.85 5.80

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

5.75 2012

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

18 16 14 12 10 8 6 4 2 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

45 40 35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

114 | WORLD MALARIA REPORT 2013

Deaths

Cabo Verde
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
283 000 211 000 494 000

%
57 43

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An.arabiensis

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes Yes No Yes Yes Yes No 1998 1998 1975 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
AL AL QN QN

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 15 10 5 0 2012 ABER (%) 20 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
5 Positivity rate (%) 4 3 2 1 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

160 140 120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

140 120 100 80 60 40 20 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 115

Central African Republic

Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 530 000 0 0 4 530 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes No No Yes No No No No No 2006 2004 2010 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN AM; QN

Year adopted
2005 2005

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

12 10 8 6 4 2 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 800 1 600 1 400 1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

116 | WORLD MALARIA REPORT 2013

Deaths

Chad
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
9 960 000 2 370 000 124 000 12 454 000

%
80 19 1

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, funestus, pharoensis, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes Yes Yes No Yes No No No No No 2003 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; AS+AQ AL; AS+AQ QN AM; QN

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20092009

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 2 P. f

III. Financing
1 200 1 000 800 600 400 200 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

18 16 14 12 10 8 6 4 2 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

400 350 300 250 200 150 100 50 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

12 10 8 6 4 2 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 117

Deaths

China
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
196 000 576 000 000 801 000 000 1 377 196 000

%
0 42 58

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (58%), P. vivax (42%) An. sinensis, anthropophagus, dirus, minimus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes No Yes Yes No Yes No Yes Yes 2003 2000 2000 2000 2006 2006 1970 1970 1970

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No 2000 2000 1970

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
ART+NQ; ART-PPQ; AS+AQ; DHA-PPQ AM; AS; PYR CQ+PQ(8d)

Year adopted
2009 2009 2006

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

CQ+PQ CQ DHA-PPQ

Year
20082009 20092013 20122012

Min
0 0 0

Median
0 0 1.15

Max
0 4.3 2.3

Follow-up No. of studies Species

28 days 28 days 42 days 1 5 2 P. v P. v P. f

III. Financing
60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

35 000 30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1.0 0.8 0.6 0.4 0.2 0 2000 Cases per 1000

Malaria admissions and deaths

60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

118 | WORLD MALARIA REPORT 2013

Deaths

Colombia
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
7 060 000 3 670 000 37 000 000 47 730 000

%
15 8 78

Parasites and vectors

Major plasmodium species: P. falciparum (27%), P. vivax (73%) Major anopheles species: An. darlingi, albimanus, nunestovari, neivai, punctimacula, pseudopunctipennis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes No No Yes No No Yes 2005 2005 1958 1984 1958 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No No 1998

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2009 AL 2004 QN(3d)+CL(5d) 2012 AS 1960s CQ+PQ(14d) 0.25 mg/kg (14 days)

P.f + P.v specic (Combo) Year Min

0

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Median
0

Max
1.3

Follow-up No. of studies Species

28 days 3 P. f

20072010

III. Financing
35 30 25 20 15 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2000, Other Nat.

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

700 600 500 400 300 200 100 0 2000 Total cases per 1000

Malaria admissions and deaths

70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 119

Deaths

Comoros
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
674 000 43 100 0 717 100

%
94 6 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (96%), P. vivax (1%) An. gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No No No No 2005 2010 2004 1997 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2003 2003 2003 2003

P.f + P.v, P.o, P.m (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20062011

Min
0

Median
0

Max
3.2

Follow-up No. of studies Species

28 days 12 P. f

III. III.Financing Financing

5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, UNICEF, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. IV.Coverage Coverage

100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 15 10 5 0 2012 ABER (%) 20 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. V.Impact Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 Cases per 1000

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

4 000 Admissions 3 000 2 000 1 000 0 2000 2001 2002 2003

Malaria admissions and deaths (100 000)

18 16 14 12 10 8 6 4 2 0

20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

120 | WORLD MALARIA REPORT 2013

Deaths

40

Congo
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 340 000 0 0 4 340 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, nili, moucheti, hancocki

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes No No No No No No No 2007 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ AL QN

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20052005 20062006

Min
5.6 2.8

Median
5.6 2.8

Max
5.6 2.8

Follow-up No. of studies Species

28 days 28 days 1 1 P. f P. f

III. Financing
14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

35 30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

25 25 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 121

Deaths

Costa Rica
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
1 2 500 4 800 000 4 802 500

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (14%), P. vivax (57%) An.albimanus

100

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A No Yes No No No Yes Yes 2009 2009 1957 1957

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

CQ+PQ(1d) CQ+PQ(7d);CQ+PQ(14d) 0.25 mg/kg (14 days), 0.5 mg/kg (7 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0

RDT positivity rate

Slide positivity rate

4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

122 | WORLD MALARIA REPORT 2013

Cte dIvoire
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
19 800 000 0 0 19 800 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ AL QN

Year adopted
2003 2003 2003 2003

ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL AS+AQ

Year
20052009 20082009

Min
0 0

Median
2.6 0

Max
7.4 0

Follow-up No. of studies Species

28 days 28 days 5 2 P. f P. f

III. Financing
70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

10 6 4 2 0 2012 ABER (%) 8 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

900 800 700 600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

120 100 80 60 40 20 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 123

Deaths

Democratic Peoples Republic of Korea South-East Asia Region

Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010 Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
146 18 700 000 6 070 000 24 770 000

%
75 25

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (100%) An.sinensis

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes No Yes No Yes Yes 2002 2002 2007 2002 1953 2000 2000 2002

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No No No No No Yes 1999 1999

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

N2006 2006 2006 2006 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

160 000 140 000 120 000 100 000 80 000 60 000 40 000 20 000 0

RDT positivity rate

Slide positivity rate

160 000 140 000 120 000 100 000 80 000 60 000 40 000 20 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

124 | WORLD MALARIA REPORT 2013

Democratic Republic of the Congo

Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
63 700 000 1 970 000 0 65 670 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, nili, moucheti

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No No No Yes 2006 2008 2007 1998 2004 2007 2007 2006 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2005 2005 2005 2005

P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20052009

Min
0

Median
3.7

Max
6.9

Follow-up No. of studies Species

28 days 7 P. f

III. Financing
300 250 200 150 100 50 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, World Bank, UNICEF,WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2007

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 Cases per 1000

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 600 Admissions 1 200 800 400 0 2000 2001 2002 2003 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Malaria admissions and deaths (100 000)

45 40 35 30 25 20 15 10 5

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 125

Deaths

Djibouti
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
0 430 000 430 000 860 000

%
0 50 50

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes N/A Yes Yes Yes Yes No No No No No 2008 2006 2008 2007 2007 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AP AS+AP AL QN

Year adopted
2008 2008 2008 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, World Bank, UNICEF, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: MIS 2009

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.0 0.6 0.4 0.2 0 2012 ABER (%) 0.8

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
1 400 1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths

35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

126 | WORLD MALARIA REPORT 2013

Deaths

Dominican Republic
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
442 000 8 350 000 1 480 000 10 272 000

%
4 81 14

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. albimanus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes No Yes Yes No Yes No 2008 2008 1946 1964 1964 1964 1964 1964

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No 1964 1964

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

CQ+PQ(3d) AS+D CQ; QN CQ+PQ 0.25 mg/kg (14 days)

P.f only Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, Other Bilaterals, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

3 500 3 000 2 500 2 000 1 500 1 000 500 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 0.8 0.6 0.4 0.2 0 2000 Total cases per 1000

Malaria admissions and deaths

18 16 14 12 10 8 6 4 2 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: <50% decrease in incidence projected 20002015

WORLD MALARIA REPORT 2013 | 127

Deaths

Ecuador
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
4 232 000 15 300 000 15 532 000

%
1 99

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (14%), P. vivax (86%) An.albimanus

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes No No Yes Yes Yes 2004 2005 1956 1956 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
AL AL QN CQ+PQ(14d)

Year adopted
2012 2004 2004 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052006

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 1 P. f

III. Financing
12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

120 000 100 000 80 000 60 000 40 000 20 000 0

RDT positivity rate

Slide positivity rate

120 000 100 000 80 000 60 000 40 000 20 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

128 | WORLD MALARIA REPORT 2013

El Salvador
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
10 7 960 6 290 000 6 297 960

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (14%), P. vivax (57%) An.albimanus, pseudopunctipennis

100

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No Yes N/A Yes Yes No Yes Yes No Yes No 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No No Yes No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
CQ+PQ CQ+PQ

Year adopted
0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

800 700 600 500 400 300 200 100 0

RDT positivity rate

Slide positivity rate

800 700 600 500 400 300 200 100 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 129

Equatorial Guinea
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
736 000 0 0 736 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, melas

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes Yes Yes No No No No No No 2010 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No Yes Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2004 2004 2004 2004 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20062011

Min
0

Median
2.8

Max
4.9

Follow-up No. of studies Species

28 days 4 P. f

III. Financing
20 16 12 8 4 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

90 80 70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

12 10 8 6 4 2 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

130 | WORLD MALARIA REPORT 2013

Deaths

Eritrea
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 350 000 1 780 000 0 6 130 000

%
71 29 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (54%), P. vivax (46%) An. gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes No No Yes 2002 2000 1995 1995 1997 1997 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
CQ+SP AS+AQ QN QN CQ+PQ

Year adopted

P.f + P.v, P.o, P.m (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20062010

Min
0

Median
4.55

Max
7.9

Follow-up No. of studies Species

28 days 8 P. f

III. Financing
25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

2.5 2.0 1.5 1.0 0.5 0 2012 ABER (%) Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

7 6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

300 250 200 150 100 50 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

3.5 3.0 2.5 2.0 1.5 1.0 0.5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 131

Deaths

Ethiopia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
917 000 60 500 000 30 300 000 91 717 000

%
1 66 33

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (56%), P. vivax (44%) An. arabiensis, pharoensis, funestus, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes No Yes Yes Yes Yes No No No No No 2004 2004 1960 1960 1960 1960 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN CQ

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

QN AL

Year
20062006 20062009

Min
10 0

Median
10 0.6

Max
10 3.2

Follow-up No. of studies Species

28 days 28 days 1 7 P. f P. f

III. Financing
180 160 140 120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

20 16 12 8 4 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

120 100 80 60 40 20 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: 50%75% decrease in incidence projected 20002015

132 | WORLD MALARIA REPORT 2013

Deaths

French Guiana, France

Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
208 000 35 200 0 243 200

%
86 14 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (36%), P. vivax (64%) An. darlingi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No N/A Yes Yes

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; AT+PG; QN+D QN+D CQ+PQ

Year adopted
2012

Yes ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
0 0 0 0 0 0 0 0 0 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

120 100 80 60 40 20 0 2000 Total cases per 1000

Malaria admissions and deaths

6 5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 133

Deaths

Gabon
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 630 000 0 0 1 630 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (75%), P. vivax (25%) An. funestus, gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No No Yes Yes No Yes Yes No No No No No 2003 2007 2003 2009 2003 2003

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ AL QN

Year adopted
2003 2003 2003 2003

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001 2002

Cases tested and potentially treated (public sector)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

180 160 140 120 100 80 60 40 20 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

134 | WORLD MALARIA REPORT 2013

Deaths

Gambia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 790 000 0 0 1 790 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, melas, pharoensis, funestus, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes 2000 1998 2008 2007 2002 2009 1998 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2005 2005 2005 2005 P.f only

Yes ACT is free for all ages in public sector No Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20072010

Min
0

Median
2.45

Max
11.9

Follow-up No. of studies Species

28 days 4 P. f

III. Financing
12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

180 160 140 120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 600 1 400 1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 135

Deaths

Ghana
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
25 400 000 0 0 25 400 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes No No Yes No No No No Yes 2004 2010 2005 1999 2003 2008 2010 2001

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

no No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AL; AS+AQ QN QN

Year adopted
2004 2004 2004 2004 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20032006 20032007

Min
0 1.7

Median
4.3 4

Max
14 13.8

Follow-up No. of studies Species

28 days 28 days 4 5

III. Financing
140 120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2003, DHS 2008

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 15 10 5 0 2012 ABER (%) 20 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

160 140 120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 000 1 750 1 500 1 250 1 000 750 500 250 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

136 | WORLD MALARIA REPORT 2013

Deaths

Guatemala
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
2 260 000 4 600 000 8 220 000 14 080 000

%
86 14 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (36%), P. vivax (64%) An. darlingi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes No Yes No Yes No 2006 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2012 CQ+PQ(3d) N/A CQ CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
16 14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, PMI/ USAID, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 000 50 000 40 000 30 000 20 000 10 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1.0 0.8 0.6 0.4 0.0 0 2000 Total cases per 1000

Malaria admissions and deaths

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 137

Deaths

Guinea
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
11 500 000 0 0 11 500 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, melas, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes Yes No No No No Yes 2009 2009 2013 2012 2012 2010 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No 2009

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted

P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20042004

Min
1

Median
1

Max
1

Follow-up No. of studies Species

28 days 1

III. Financing
25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

800 700 600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

9 8 7 6 5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

138 | WORLD MALARIA REPORT 2013

Deaths

Guinea-Bissau
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 660 000 0 0 1 660 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No No No No Yes Yes No Yes No No No No Yes 2005 2008 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20062008

Min
3.6

Median
3.6

Max
3.6

Follow-up No. of studies Species

28 days 1 P. f

III. Financing
120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, UNICEF, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 600 1 400 1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

90 80 70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 139

Deaths

Guyana
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
278 000 461 000 55 700 794 700

%
35 58 7

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (64%), P. vivax (36%) An. darlingi, aquasalis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes Yes Yes No No No 2005 2005 1946 1946 2005 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2004 AL+PQ(1d) 2004 QN+T 2004 CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2009

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 200 1 000 800 600 400 200 0 2000 Total cases per 1000

Malaria admissions and deaths

25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Impact: Increase in incidence 20002012

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

140 | WORLD MALARIA REPORT 2013

Deaths

Haiti
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
5 390 000 4 780 000 0 10 170 000

%
53 47 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. albimanus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No Yes N/A Yes Yes Yes Yes No No Yes No 2012 2012 2011 1988 2011

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2004 CQ+PQ(1d) 2004 2004 CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
9 8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

45 40 35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

9 8 7 6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 200 1 000 800 600 400 200 0 2000 Total cases per 1000

Malaria admissions and deaths

35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 141

Deaths

Honduras
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 110 000 4 670 000 2 160 000 7 940 000

%
14 59 27

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (9%), P. vivax (91%) An. albimanus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes N/A Yes Yes Yes Yes Yes No Yes No 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

CQ+PQ(1d) SP 2011 QN CQ+PQ(14d) 0.25 mg/kg (14 days)

P.f + P.v specic (Combo) Year Min

0

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

CQ

Median
0

Max
0

Follow-up No. of studies Species

28 days 1

20082009

III. Financing
3.5 3.0 2.5 2.0 1.5 1.0 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

40 000 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
1.0 0.8 0.6 0.4 0.2 0 2000 Total cases per 1000

Malaria admissions and deaths

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

142 | WORLD MALARIA REPORT 2013

Deaths

India
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
272 000 000 829 000 000 136 000 000 1 237 000 000

%
22 67 11

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (50%), P. vivax (50%) An. culicifacies, uviatilis, stephensi, minimus, dirus, annularis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes N/A Yes Yes Yes Yes Yes Yes No No Yes 2001 2001 1953 1953 1958 1953 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+SP+PQ AS+SP+PQ QN+D; QN+T AM; AS; QN CQ+PQ(14d)

Year adopted
2004 2004 2004 2004 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20052007

Min
0

Median
0

Max
4

Follow-up No. of studies Species

28 days 9

III. Financing
160 120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, World Bank

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
5 Positivity rate (%) 4 3 2 1 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

2.5 2.0 1.5 1.0 0.5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

6 000 5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths

1 800 1 500 1 200 900 600 300 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: 50%75% decrease in incidence projected 20002015

WORLD MALARIA REPORT 2013 | 143

Deaths

Indonesia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
42 000 000 109 000 000 93 300 000 247 300 000

%
17 44 39

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (55%), P. vivax (45%) An. sundaicus, balabacensis, maculatus, farauti, subpictus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes No No Yes 2006 1959 2007 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2008 AS+AQ; DHA-PP+PQ 2004 QN+D+PQ 2004 AM; AS; QN 2008 AS+AQ; DHA-PP+PQ(14d) 0.25 mg/kg (14 days) P.f only, P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ DHA-PPQ

Year
20032006 20042008

Min
0 2.7

Median
8.8 4.1

Max
24.1 4.8

Follow-up No. of studies Species

28 days 42 days 8 3

III. Financing
50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, UNICEF, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2007. Other Nat.

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

3.0 2.5 2.0 1.5 1.0 0

RDT positivity

Slide positivity rate

Conrmed cases (per 1000)

6 000 5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths

1 000 800 600 400 200 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

144 | WORLD MALARIA REPORT 2013

Deaths

Iran (Islamic Republic of )

Conrmed cases per 1000 population Insufficient data 0

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2011 reported data

00.1 0.11.0 1.010 1050 50100 100

Based on 2011 reported data

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
444 764 000 75 700 000 76 464 000

%
1 99

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (10%), P. vivax (90%) An.stephensi, culicifacies, uviatilis, Superpictus

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes No Yes Yes 2005 2005 1949 1949 1949 1949 1949 1949

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No No No Yes Yes 1949 1949 2010 1949

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

2006 AS+SP 2006 AL AS; QN+D 2005 CQ+PQ(14d & 8w) 0.75 mg/kg (8 weeks)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20052010

Min
0

Median
0

Max
0.5

Follow-up No. of studies Species

28 days 8 P. f

III. Financing
16 14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

50 30 20 10 0 2012 ABER (%) 40 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
3.0 2.5 2.0 1.5 1.0 0.5 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

25 000 Confirmed cases 20 000 15 000 10 000 5 000 0 2000 2001 2002 2003 2004

RDT positivity rate

Slide positivity rate

18 000 15 000 12 000 9 000 6 000 3 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases

Indigenous malaria cases by species

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 145

Kenya
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
15 500 000 17 300 000 10 400 000 43 200 000

%
36 40 24

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, funestus, merus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes No 2006 2010 2003 2001 2009 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2004 2004 2004 2004 P.f only

Yes ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20022008

Min
0

Median
2.65

Max
6.6

Follow-up No. of studies Species

28 days 12

III. Financing
120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, World Bank

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2003, DHS 2009

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

18 16 14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

40 35 30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

180 160 140 120 100 80 60 40 20 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

146 | WORLD MALARIA REPORT 2013

Deaths

Kyrgyzstan
Conrmed cases per 1000 population Insufficient data 0

European Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
0 22 900 5 450 000 5 472 000

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (0%) An.superpictus, pulcherrimus, claviger, hyrcanus, messeae

100

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes No Yes Yes 2003 2006 2001 2002 2007 2007 2007 2007 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No Yes No No Yes Yes 2007 2010 2007 2007

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
1.6 Contribution (US$m) 1.2 0.8 0.4 0 2000 2001 2002 2003 2004

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
5 Positivity rate (%) 4 3 2 1 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

3 000 2 500 2 000 1 500 1 000 500 0

RDT positivity rate

Slide positivity rate

3 000 2 500 2 000 1 500 1 000 5 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 147

Lao Peoples Democratic Republic

Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
2 390 000 1 530 000 2 720 000 6 640 000

%
36 23 41

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (87%), P. vivax (13%) An. dirus, minimus, maculatus, jeyporiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes No No Yes No No 2003 2000 2010 2003 2005 2005 2008 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No 2012 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL QN+D AS+AL CQ+PQ(14d)

Year adopted
2001 2001 2001 2001

P.f only, P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052013

Min
0

Median
0

Max
8.3

Follow-up No. of studies Species

28 days 11 P. f

III. Financing
9 8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, PMI/ USAID, Other Bilaterals, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

10 8 6 4 2 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

8 7 6 5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

25 000 20 000 15 000 10 000 5 000 0 2000 Cases per 1000

Malaria admissions and deaths

400 350 300 250 200 150 50 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

148 | WORLD MALARIA REPORT 2013

Deaths

Liberia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
4 190 000 0 0 4 190 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes Yes Yes No No No No Yes 2005 2008 2009 2005 2005 2005 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2004 2004 2004 2004 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20072007

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 2 P. f

III. Financing
35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: MIS, 2009, MIS 2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

500 400 300 200 100 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

6 000 5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 149

Deaths

Madagascar
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 690 000 15 600 000 0 22 290 000

%
30 70 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. funestus, gambiae, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes Yes No No No No Yes 2004 2009 1993 2006 2006 2006 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes Yes 1993 2006

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2006 2006 2006 2006

P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20062007

Min
0

Median
0

Max
8.7

Follow-up No. of studies Species

28 days 10

III. Financing
80 70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2009, MIS 2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

5 3 2 1 0 2012 ABER (%) 4 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

18 16 14 12 10 8 6 4 2 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

80 70 60 50 40 30 20 10 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: <50% decrease in incidence projected 20002015

150 | WORLD MALARIA REPORT 2013

Deaths

Malawi
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
15 900 000 0 0 15 900 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. funestus, gambiae, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes No Yes Yes No No No No Yes 2006 2010 2007 1993 2011 2007 2009 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL AS+AQ QN

Year adopted
2007 2007 2007 2007 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20052005 20052005

Min
0 7.1

Median
1.8 7.1

Max
3.6 7.1

Follow-up No. of studies Species

28 days 28 days 2 1

III. Financing
60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2004, DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 15 10 5 0 2012 ABER (%) 20 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 400 1 200 1 00 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 151

Deaths

Malaysia
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
3 134 1 190 000 28 100 000 29 290 000

%
4 96

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (18%), P. vivax (24%) An.balabacensis, donaldi, maculatus, sundaicus, avirostris

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No Yes N/A Yes Yes No Yes Yes Yes Yes 1995 1995 1967

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes No Yes Yes Yes Yes Yes 1975

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

N2006 AS+MQ 2006 QN+T 2006 QN+T 2006 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

250 200 150 100 50 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

14 000 12 000 10 000 8 000 6 000 4 000 2 000 0

RDT positivity rate

Slide positivity rate

14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

152 | WORLD MALARIA REPORT 2013

Mali
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
13 400 000 1 490 000 0 14 890 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes Yes Yes No Yes No No No Yes 2005 2007 2003 2008 2008 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes 2008 1993

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AL; AS+AQ AL QN

Year adopted
2007 2007 2007

P.f only, P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20022006 20042008

Min
0 0

Median
2 3

Max
7.6 6

Follow-up No. of studies Species

28 days 28 days 4 6

III. Financing
30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source:DHS 2006, DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 153

Deaths

Mauritania
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
2 240 000 1 180 000 380 000 3 800 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, pharoensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes Yes Yes Yes No Yes Yes No Yes 1998 2008 2011 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AL; AS+AQ QN

Year adopted

P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: MIS 2007

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

700 600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

7 6 5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

154 | WORLD MALARIA REPORT 2013

Deaths

Mayotte
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
1 3 480 213 000 216 480

%
2 98

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (84%), P. vivax (8%) An.Funestus, An.gambiae, s.s.

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes 2010 2010 1980

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

No Yes No Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
AL QN CQ+PQ

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
0 0 0 0 0 0 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 20 Cases due to P. vivax (%) 15 10 5 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
3.0 Positivity rate (%)

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2.5

2.0 2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

900 800 700 600 500 400 300 200 100 0

RDT positivity rate

Slide positivity rate

250 200 150 100 50 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 155

Mexico
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
71 4 160 000 117 000 000 121 160 000

%
3 97

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (100%) An.pseudopunctipennis, albimanus, punctimacula

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No Yes N/A Yes Yes No Yes Yes No Yes Yes 2012 2012

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No No No Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
CQ+PQ CQ+PQ

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

156 | WORLD MALARIA REPORT 2013

Mozambique
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
25 200 000 0 0 25 200 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. funestus, gambiae, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN

Year adopted
2004 2004 2004 P.f only

Yes ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052008

Min
0

Median
1.6

Max
3.1

Follow-up No. of studies Species

28 days 4

III. Financing
6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 15 10 5 0 2012 ABER (%) 20 Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

700 600 500 400 300 200 100 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 157

Deaths

Myanmar
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
19 500 000 12 100 000 21 100 000 52 700 000

%
37 23 40

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (65%), P. vivax (35%) An. minimus, dirus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes No N/A Yes Yes Yes No Yes Yes No No Yes 2003 2003 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2008 AL; AM; AS+MQ; DHA-PPQ; PQ 2008 AS+D; AS+T 2008 AM; AS; QN 2008 CQ+PQ(14d) 0.25 mg/kg (14 days) P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

DHA-PPQ AL

Year
20052011 20072011

Min
0 0

Median
0.7 0

Max
5 5.9

Follow-up No. of studies Species

28 days 28 days 14 13 P. f P. f

III. Financing
25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, PMI/ USAID, Other Bilaterals, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

5 4 3 2 1 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

10 Cases per 1000 8 6 4 2 0 2000 2001 2002 2003 2004

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

100 000 80 000 60 000 40 000 20 000 0 2000

Malaria admissions and deaths

3 000 2 500 2 000 1 500 1 000 500 0

Admissions

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

158 | WORLD MALARIA REPORT 2013

Deaths

Namibia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 510 000 113 000 633 000 2 256 000

%
67 5 28

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes No No Yes 1998 1965 1965 2007 2010 1990 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN AL

Year adopted
2006 2006 2006 2006 2006

P.f only, P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2007

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

45 000 40 000 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
45 000 40 000 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0 2000 Cases per 1000

Malaria admissions and deaths

2 000 Deaths 1 500 1 000 500 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Admissions

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 159

Nepal
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 020 000 22 000 000 4 510 000 27 530 000

%
4 80 16

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (30%), P. vivax (70%) An. uviatilis, annularis, maculatus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes 2007 2007 1962 1962 1962 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL+PQ AL+PQ QN CQ+PQ(14d)

Year adopted
2004 2004 2004

Yes ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052010

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 5 P. f

III. Financing
7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

14 000 12 000 10 000 8 000 6 000 4 000 2 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths

45 40 35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

160 | WORLD MALARIA REPORT 2013

Deaths

Nicaragua
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
77 900 2 930 000 2 980 000 5 987 900

%
1 49 50

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (20%), P. vivax (80%) An. albimanus, pseudopunctipennis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes No Yes Yes No Yes Yes 2004 2004 1959

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

CQ+PQ AS+MQ; AS+SP 2011 QN+CL CQ+PQ(7d) 0.5 mg/kg (7 days)

P.f + P.v specic (Combo) Year Min

0

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

CQ

Median
0

Max
0

Follow-up No. of studies Species

28 days 1 P. f

20052006

III. Financing
3.0 2.5 2.0 1.5 1.0 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

50 40 30 20 10 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
250 200 150 100 50 0 2000 Total cases per 1000

Malaria admissions and deaths

9 8 7 6 5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 161

Deaths

Niger
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
11 800 000 5 320 000 380 000 17 120 000

%
69 31 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes Yes Yes 2005 2003 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2005 2005 2005 2005

No ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20062006

Min
4.4

Median
4.4

Max
4.4

Follow-up No. of studies Species

28 days 1

III. Financing
3 000 2 500 2 000 1 500 1 000 500 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, World Bank, UNICEF

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2006

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 600 Admissions 1 200 800 400 0 2000 2001 2002 2003 Cases per 1000

Malaria admissions and deaths (100 000)

30 25 20 15 10 5 0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

162 | WORLD MALARIA REPORT 2013

Deaths

Nigeria
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
169 000 000 0 0 169 000 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis, Moucheti, melas, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes No Yes Yes No No No No No 2001 2009 2007 2010 2004 2010 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; AS+AQ AL; AS+AQ QN AM; AS; QN

Year adopted
2004 2004 2004 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL AS+AQ

Year
20022007 20042006

Min
0 0

Median
0 0

Max
2 7.8

Follow-up No. of studies Species

28 days 28 days 5 5

III. Financing
180 160 140 120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2003, DHS 2008, MIS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4 Cases per 1000

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 2 1 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 600 500 400 300 200 100 0 2000

Malaria admissions and deaths (100 000)

8 7 6 5 4 3 2 1 0

Admissions

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 163

Deaths

Pakistan
Conrmed cases per 1000 population Insufficient data 0

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2009 reported data

00.1 0.11.0 1.010 1050 50100 100

Based on 2009 reported data

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
51 800 000 124 000 000 3 030 000 178 030 000

%
29 69 2

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (25%), P. vivax (75%) An. culicifacies, stephensi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes N/A Yes Yes Yes Yes Yes Yes Yes No No 2008 2008 1961 1961 2011 1961 2009 2007 2012 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

CQ 2007 AS+SP QN 2007 AS; QN 2007 CQ+PQ(14d) 0.25 mg/kg (14 days) P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20072011

Min
0

Median
0

Max
1.5

Follow-up No. of studies Species

28 days 7 P. f

III. Financing
16 14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

2.0 Cases per 1000 1.6

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

70 000 60 000 50 000 40 000 30 000 20 000 10 000 0 2000

Malaria admissions and deaths

300 250 200 150 100 50 0

Admissions

1.2 0.8 0.4 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

164 | WORLD MALARIA REPORT 2013

Deaths

Panama
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
167 000 2 710 000 928 000 3 805 000

%
4 71 24

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (100%) An. albimanus, pseudopunctipennis, punctimacula, aquasalis, darlingi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No No No Yes N/A Yes Yes Yes Yes Yes No Yes No 1957 1957 1957

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

AL SP+PQ MQ CQ+PQ(7d);CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, PMI/ USAID, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases
120 100 80 60 40 20 0 2000 Total cases per 1000

Malaria admissions and deaths

5 4 3 2 1 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: <50% decrease in incidence projected 20002015

WORLD MALARIA REPORT 2013 | 165

Deaths

Papua New Guinea

Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 740 000 430 000 0 7 170 000

%
94 16 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (89%), P. vivax (11%) An. punctulatus, farauti, koliensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes N/A Yes Yes 2004 2005 2000 2010 2010 2004 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL DHA-PPQ AM; AS AL+PQ

Year adopted
2008 2008 2008 2009

Yes ACT is free for all ages in public sector No Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

DHA-PPQ AL

Year
20052007 20052007

Min
12 2.7

Median
12 2.7

Max
12 2.7

Follow-up No. of studies Species

42 days 28 days 1 1 P. f P. f

III. Financing
40 35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

35 000 30 000 25 000 20 000 15 000 10 000 5 000 0 2000 Cases per 1000

Malaria admissions and deaths

800 700 600 500 400 300 200 100 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: <50% decrease in incidence projected 20002015

166 | WORLD MALARIA REPORT 2013

Deaths

Paraguay
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
15 497 000 6 190 000 6 687 000

%
7 93

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An.darlingi, albitarsis

Programme phase: Pre-elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No No N/A Yes Yes Yes No Yes No Yes No 1957 1957 1957 2005 1957 1957

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No Yes Yes Yes No 1957 1957 1957 1957 1957

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

Medicine

Year adopted

First-line treatment of unconrmed malaria AL First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria CQ+PQ Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax 0.25 mg/kg (14 days), 15 mg/kg (14 days adults)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

70 60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 167

Peru
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 350 000 3 450 000 25 200 000 30 000 000

%
5 12 84

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (11%), P. vivax (89%) An. darlingi, pseudopunctipennis, albimanus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes Yes No No Yes Yes

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+MQ CQ+PQ

Year adopted

Year Min
1.1

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+MQ

Median
1.1

Max
1.1

Follow-up No. of studies Species

28 days 1 P. f

20052006

III. Financing
140 120 100 80 60 40 20 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, PMI/ USAID

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

40 35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4.0 3.5 3.0 2.5 2.0 1.5 1.0 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 000 2 500 2 000 1 500 1 000 500 0 2000 Total cases per 1000

Malaria admissions and deaths

30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

168 | WORLD MALARIA REPORT 2013

Deaths

Philippines
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 940 000 70 200 000 19 600 000 96 740 000

%
7 73 20

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (69%), P. vivax (31%) An. avirostris, maculatus, balabacensis, Litoralis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes 2006 2000 2002 2004 2003 2003 2006 2007 2011 2010 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No 2009 2009

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2009 AL 2009 AL+PQ 2002 QN+T 2002 QN+T 2002 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

CQ AL

Year
20002010 20052009

Min
0 0

Median
0 0

Max
0 5.6

Follow-up No. of studies Species

28 days 28 days 5 9 P. f P. f

III. Financing
40 35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

1.0 0.8 0.6 0.4 0.2 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 000 50 000 40 000 30 000 20 000 10 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

5 000 4 000 3 000 2 000 1 000 0 2000 Cases per 1000

Malaria admissions and deaths

600 500 400 300 200 100 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 169

Deaths

Republic of Korea
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
22 3 760 000 45 200 000 48 960 000

%
8 92

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (7%), P. vivax (93%) An.sinensis

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No Yes N/A Yes Yes No No Yes 2001 2001 2001 2001 2011

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

No No No No Yes Yes Yes 2001 1963

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

CQ N2006 2006 2006 2006 CQ+PQ(14d) 0.25 mg/kg (14 days), 0.25 mg base/kg

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

1.2 1.0 0.8 0.6 0.4 0.2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0

RDT positivity rate

Slide positivity rate

4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

170 | WORLD MALARIA REPORT 2013

Rwanda
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
11 500 000 0 0 11 500 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No No Yes No 2004 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN AM; QN

Year adopted
2005 2005 2005 2005

No ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20042007

Min
0

Median
1.5

Max
6.9

Follow-up No. of studies Species

28 days 3

III. Financing
45 40 35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005, DHS 2008, DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 000 1 600 1 200 800 400 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 171

Deaths

Sao Tome and Principe

Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
188 000 0 0 188 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes No Yes No Yes Yes Yes Yes 2005 2003 2004 2001 2008 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ AL QN

Year adopted
2004 2004 2004 2004

Yes ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, Other Bilaterals, World Bank, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2009

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

120 100 80 60 40 20 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

400 Cases per 1000

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

300 200 100 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 12 000 10 000 8 000 6 000 4 000 2 000 0 2000

Malaria admissions and deaths (100 000)

250 200 150 100 50 0

Admissions

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

172 | WORLD MALARIA REPORT 2013

Deaths

Saudi Arabia
Conrmed cases per 1000 population Insufficient data 0

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2011 reported data

00.1 0.11.0 1.010 1050 50100 100

Based on 2011 reported data

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
68 2 300 000 26 000 000 28 300 000

%
8 92

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An.arabiensis, sergentii, funestus, bacroftii, albimanus, balabacensis

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes No Yes No Yes 1980 1980 1963 1985 1985 1990

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes No No No Yes Yes 1980 1980 1990 1990

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine
AS+SP AL AS; AM; QN CQ+PQ(14d)

Year adopted

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
5 Positivity rate (%) 4 3 2 1 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

7 000 6 000 5 000 4 000 3 000 2 000 1 000 0

RDT positivity rate

Slide positivity rate

5 000 4 000 3 000 2 000 1 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 173

Senegal
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
13 200 000 549 000 0 13 749 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, funestus, pharoensis, melas

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes Yes Yes No No No No Yes 1998 1998 2005 2010 2007 2007 2010 2010 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No 2012

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AL; AS+AQ QN

Year adopted
2005 2005 2005

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20022008 20022008

Min
0 0

Median
0 0.85

Max
0.5 3.2

Follow-up No. of studies Species

28 days 28 days 7 6

III. Financing
40 35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005, MIS 2006, MIS 2009, DHS 2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

250 200 150 100 50 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

18 16 14 12 10 8 6 4 2 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

174 | WORLD MALARIA REPORT 2013

Deaths

Sierra Leone
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
5 980 000 0 0 5 980 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, melas

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No Yes Yes Yes 2010 2005 2005 2010 2008 2010 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AL; AS+AQ QN AM; QN

Year adopted
2004 2004 2004 2004 P.f only

Yes ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken Yes System for monitoring of adverse reaction to antimalarials exists

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ

Year
20042004

Min
27

Median
27

Max
27

Follow-up No. of studies Species

28 days 1

III. Financing
16 14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, UNICEF, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2008

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

45 40 35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

300 250 200 150 100 50 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 600 Admissions 1 200 800 400 0 2000 2001 2002 2003 Cases per 1000

Malaria admissions and deaths (100 000)

160 140 120 100 80 60 40 20 0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 175

Deaths

Solomon Islands
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
544 000 0 5 500 549 500

%
99 0 1

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (64%), P. vivax (36%) An. farauti, punctulatus, koliensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes No Yes Yes No No 2009 1996 2009 1968 2007 2008 2009 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2009 AL 2009 AL 2002 QN 2002 AS; AL 2002 AL+PQ(14d) 0.25 mg/kg (14 days) P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL AL

Year
20082013 20082013

Min
0 4

Median
0 5.1

Max
6.3 31.6

Follow-up No. of studies Species

28 days 28 days 3 3 P. f P. v

III. Financing
10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, Other Bilaterals, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

80 70 60 50 40 30 20 10 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

250 200 150 100 50 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 000 1 600 1 200 800 400 0 2000 Cases per 1000

Malaria admissions and deaths

80 70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

176 | WORLD MALARIA REPORT 2013

Deaths

Somalia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2011 reported data

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

Based on 2011 reported data

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
7 140 000 3 060 000 0 10 200 000

%
70 30 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes No No No No No No 2005 2005 2004 2006 2006 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No No No No 2006

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+SP AS+SP QN AS; QN CQ+PQ(14d)

Year adopted
2006 2006 2006 2006 2006

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20052006

Min
0

Median
0.5

Max
1

Follow-up No. of studies Species

28 days 2 P. f

III. Financing
14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund, Other Bilaterals, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

2.5 1.5 1.0 0.5 0 2012 ABER (%) 2.0

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

10 000 8 000 6 000 4 000 2 000 0 2000 Cases per 1000

Malaria admissions and deaths

90 80 70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 177

Deaths

South Africa
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
2 100 000 3 140 000 47 100 000 52 340 000

%
4 6 90

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (99%), P. vivax (1%) An. arabiensis, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes Yes Yes No Yes Yes Yes Yes No No No No No 1930 1997 2001

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; QN+CL; QN+D AS; QN QN AL+PQ; CQ+PQ

Year adopted
2001 2001 2001 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20072007

Min
0

Median
2.6

Max
5.2

Follow-up No. of studies Species

28 days 2 P. f

III. Financing
60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

30 000 25 000 20 000 15 000 10 000 5 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths

450 400 350 300 250 200 150 100 50 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

178 | WORLD MALARIA REPORT 2013

Deaths

Sri Lanka
Conrmed cases per 1000 population Insufficient data 0 00.1 0.11.0 1.010

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
17 501 000 20 600 000 21 101 000

%
2 98

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (17%), P. vivax (83%) An.culicifacies, subpictus, annularis, varuna

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes Yes 1992 2004 1945 1911

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes Yes Yes No Yes Yes 2008 1958 2008

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

N2006 AL+PQ 2006 2006 QN 2006 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
14 12 10 8 6 4 2 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

45 40 35 30 25 20 15 10 5 0 2012 Cases due to P. vivax (%) 100 80 60 40 20 80 2000 2001 2002

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

250 000 200 000 150 000 100 000 50 000 0

RDT positivity rate

Slide positivity rate

250 000 200 000 150 000 100 000 50 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 179

South Sudan*
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
10 800 000 0 0 10 800 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, funestus, nili

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes No Yes Yes Yes No No No No No 2008 2008 2006 2006 2005 2006 2012

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ AL AM; AS; QN AS+AQ+PQ

Year adopted
2006 2006 2006 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20032005 20042004

Min
1 2.8

Median
3.05 2.8

Max
5.1 2.8

Follow-up No. of studies Species

28 days 28 days 2 1

III. Financing
60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

2.5 1.5 1.0 0.5 0 2012 ABER (%) 2.0

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

10 000 8 000 6 000 4 000 2 000 0 2000 Cases per 1000

Malaria admissions and deaths

1 400 1 200 1 000 800 600 400 200 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

*

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

180 | WORLD MALARIA REPORT 2013

In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/ A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

Deaths

Sudan
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
30 900 000 6 320 000 0 37 220 000

%
83 17 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (95%), P. vivax (5%) An. arabiensis, funestus, gambiae, nili, pharoensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No No Yes No Yes Yes No Yes No No No 2005 2010 1956 2009 2005 2004 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+SP AS+SP AL AM; QN AL

Year adopted
2004 2004 2006 2004 2004 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP AL

Year
20052010 20052010

Min
0 0

Median
2 0

Max
5.3 4.5

Follow-up No. of studies Species

28 days 28 days 8 11 P. f P. f

III. Financing
90 80 70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: MIS 2009

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

35 30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

180 000 150 000 120 000 90 000 60 000 30 000 0 2000 Cases per 1000

Malaria admissions and deaths

3 000 2 500 2 000 1 500 1 000 500 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 181

Deaths

Suriname
Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2010 reported data

00.1 0.11.0 1.010 1050 50100 100

Based on 2010 reported data

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
83 900 0 451 000 534 900

%
16 0 84

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (43%), P. vivax (57%) An. darlingi

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No No Yes Yes Yes Yes Yes Yes No No No 2006 2006 1955 1955 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No 2000 2000

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

AL+PQ AS+MQ AS 2004 CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min
0

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Median
2.35

Max
4.7

Follow-up No. of studies Species

28 days 2 P. f

20052011

III. Financing
1.0 0.8 0.6 0.4 0.2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Global Fund

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

100 80 60 40 20 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

40 35 30 25 20 15 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

400 350 300 250 200 150 100 50 0 2000 Total cases per 1000

Malaria admissions and deaths

30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

182 | WORLD MALARIA REPORT 2013

Deaths

Swaziland
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
0 345 000 886 000 1 231 000

%
0 28 72

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes No No Yes Yes Yes No Yes No No No Yes 2002 2010 1946 2010 2010 2010 2010 2010

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No 2012 2010

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL QN QN

Year adopted
2009 2009

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2007

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

9 8 7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

1 600 1 400 1 200 1 000 800 600 400 200 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 000 1 600 1 200 800 400 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 183

Deaths

Tajikistan
Conrmed cases per 1000 population Insufficient data 0

European Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
22 2 150 000 5 860 000 8 010 000

%
27 73

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (100%) An.superpictus, pulcherrimus

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes No Yes Yes 2006 2006 1997 1998 1997 2004 1997 2004 1997

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

No Yes No Yes No Yes Yes 2004 1997 2004 2000

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

AL QN AN CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

160 140 120 100 80 60 40 20 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
10 Positivity rate (%) 8 6 4 2 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

25 000 Confirmed cases 20 000 15 000 10 000 5 000 0 2000 2001 2002 2003 2004

RDT positivity rate

Slide positivity rate

25 000 20 000 15 000 10 000 8 000 6 000 4 000 2 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases

Indigenous malaria cases by species

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

184 | WORLD MALARIA REPORT 2013

Thailand
Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
5 340 000 28 000 000 33 400 000 66 740 000

%
8 42 50

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (40%), P. vivax (60%) An. dirus, minimus, maculatus, sundaicus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes Yes Yes No Yes No 1992 1992 1953 1953 1991 1953 1995 1995 1965 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes No Yes No No 1958 1958

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2004 AS+MQ QN+D 2004 AS; QN 2004 CQ+PQ(14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+QM

Year
20012009

Min
0

Median
0.5

Max
10.4

Follow-up No. of studies Species

28 days 20

III. Financing
30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

16 14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
14 12 10 8 6 4 2 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

1.4 1.2 1.0 0.8 0.6 0.4 0.2 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

18 000 16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 2000 Cases per 1000

Malaria admissions and deaths

700 600 500 400 300 200 100 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 185

Deaths

Democratic Republic of Timor-Leste

Conrmed cases per 1000 population/ Parasite prevalence (PP)

South-East Asia Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
858 000 256 000 0 1 114 000

%
77 23 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (56%), P. vivax (44%) An. subpictus, barbirostris

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes No No Yes No No No 2005 2008 2006 2007 2007 2000 2007 2006

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No 2012 2009

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

AL QN+D AM; AS; QN CQ+PQ(14d) 0.50 mg/kg (14 days) P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
9 8 7 6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

25 20 15 10 5 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 000 1 600 1 200 800 400 0 2000 Cases per 1000

Malaria admissions and deaths

80 70 60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

186 | WORLD MALARIA REPORT 2013

Deaths

Togo
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 640 000 0 0 6 640 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, melas, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes No No No No No Yes 2004 2011 2011 2003 2010 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No Yes No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL; AS+AQ AL; AS+AQ QN

Year adopted
P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+AQ AL

Year
20052009 20052009

Min
0 0

Median
0 0.7

Max
6 4.4

Follow-up No. of studies Species

28 days 28 days 8 8 P. f P. f

III. Financing
18 15 12 9 6 3 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, Other Bilaterals, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

20 12 8 4 0 2012 ABER (%) 16

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 187

Deaths

Turkey
Conrmed cases per 1000 population Insufficient data 0

European Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
1 2 500 74 000 000 74 002 500

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (0%) An.sacharovi, superpictus

100

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No Yes N/A Yes No Yes No Yes No 1926 1926 1926 1926 2007

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

No Yes No No No Yes Yes 2010 1983 1930

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

CQ+PQ(14d) 0.50 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

12 000 10 000 8 000 6 000 4 000 2 000 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
10 Positivity rate (%) 8 6 4 2 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

14 000 12 000 10 000 8 000 6 000 4 000 2 000 0

RDT positivity rate

Slide positivity rate

12 000 10 000 8 000 6 000 4 000 2 000 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

188 | WORLD MALARIA REPORT 2013

Uganda
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
32 700 000 3 630 000 0 36 330 000

%
90 10 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes Yes No No No No Yes 2006 2013 2005 2012 2000 1997 2006 2006 2005

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2004 2004 2004 2004 P.f only

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20022008

Min
0

Median
2.3

Max
8.9

Follow-up No. of studies Species

28 days 8

III. Financing
250 200 150 100 50 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2006, MIS 2009, DHS 2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

18 16 14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 189

Deaths

United Republic of Ta nzania (Mainland)

Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
33 900 000 12 500 000 0 46 400 000

%
73 27 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, arabiensis, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

No No Yes No Yes Yes Yes No Yes No No No No Yes 2006 2001 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2004 2004 2004 2004

P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20022008

Min
0

Median
2.85

Max
8.6

Follow-up No. of studies Species

28 days 8

III. Financing
250 200 150 100 50 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2005, DHS 2008, DHS 2010

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

25 20 15 10 5 0 2012 ABER (%) Cases due to P. vivax (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

80 70 60 50 40 30 20 10 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

60 50 40 30 20 10 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

190 | WORLD MALARIA REPORT 2013

Deaths

United Republic of Ta nzania (Zanzibar)

Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
1 410 000 0 0 1 410 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No No No Yes 2005 2008 2006 2012 2004 2007 2004 2003 2012 2003

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes No No 2008 2011 2011

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+AQ AS+AQ QN QN

Year adopted
2004 2004 2004 2004

P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20062007

Min
0

Median
0

Max
0

Follow-up No. of studies Species

42 days 1 P. f

III. Financing
8 Contribution (US$m) 6 4 2 0 2000 2001 2002 2003 2004

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, PMI/ USAID, Other Bilaterals, WHO

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

40 Cases due to P. vivax (%) ABER (%) 30 20 10

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

0 2012

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

20 16 12 8 4 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths

40 35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

WORLD MALARIA REPORT 2013 | 191

Deaths

Uzbekistan
Conrmed cases per 1000 population Insufficient data 0

European Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
Number of active foci Number of people living within active foci Number of people living in malaria-free areas Total

2012
0 0 28 500 000 28 500 000

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (0%), P. vivax (0%) An.superpictus, pulcherrimus, hyrcanus, claviger

100

Programme phase: Elimination

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes Yes No Yes Yes 2005 2005 1925 1925 1925 1939 1939 1939 1939

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted Foci and case investigation undertaken Case reporting from private sector is mandatory

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes 1925 1925 1939 1939 1925 1925

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax

Medicine

Year adopted

CQ+PQ (14d) 0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine Year Min Median Max Follow-up No. of studies Species

III. Financing
2.5 2.0 1.5 1.0 0.5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
1.0 Positivity rate (%) 0.8 0.6 0.4 0.2 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

140 120 100 80 60 40 20 0

RDT positivity rate

Slide positivity rate

70 60 50 40 30 20 10 0 2000

Among indigenous cases

Among total cases

Malaria cases by source

Confirmed cases Confirmed cases

Indigenous malaria cases by species

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total cases

Imported cases

Indigenous cases (all species)

Indigenous cases (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

192 | WORLD MALARIA REPORT 2013

Vanuatu
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
245 000 0 2 470 247 470

%
99 0 1

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (32%), P. vivax (68%) An. farauti

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes No No Yes N/A Yes No Yes No No Yes Yes No No 2008 1990 2010 2009 2009 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2009 2009 AL 2002 QN 2002 QN 2002 AL+PQ(14d) 0.25 mg/kg (14 days) P.f + all species (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20112012

Min
0

Median
0

Max
0

Follow-up No. of studies Species

28 days 1 P. v

III. Financing
6 5 4 3 2 1 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: Other Nat.

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

35 30 25 20 15 10 5 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

18 000 15 000 12 000 9 000 6 000 3 000 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1 200 1 000 800 600 400 200 0 2000 Cases per 1000

Malaria admissions and deaths

16 14 12 10 8 6 4 2 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 193

Deaths

Venezuela (Bolivarian Republic of )

Conrmed cases per 1000 population Insufficient data 0

Region of the Americas

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

00.1 0.11.0 1.010 1050 50100 100

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
779 000 4 850 000 24 300 000 29 929 000

%
3 16 81

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (25%), P. vivax (75%) An. darlingi, aquasalis, nuneztovari, braziliensis, albitarsis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes No 2005 2005 1936 1936 2004

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2004 AL+MQ+PQ 2004 QN+CL; QN+D; QN+T 2004 AM; QN 2004 CQ+PQ(14d) 0.25 mg/kg (14 days)

Year Min Median Max Follow-up No. of studies Species

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

III. Financing
60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs

No data reported for 2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

10 8 6 4 2 0 2012 ABER (%)

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

2.0 1.6 1.2 0.8 0.4 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

1.0 0.8 0.6 0.4 0.2 0 2000 Total cases per 1000

Malaria admissions and deaths

45 40 35 30 25 20 15 10 5 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Impact: Increase in incidence 20002012

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

194 | WORLD MALARIA REPORT 2013

Deaths

Viet Nam
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Western Pacic Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
15 900 000 18 100 000 56 800 000 90 800 000

%
18 20 63

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (63%), P. vivax (37%) An. minimus, dirus, sundaicus, maculatus, sinensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No No N/A Yes Yes Yes Yes Yes Yes No Yes Yes 1992 1992 1958 1958 1958 2003 2003 1960 1980

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes No No No 1958 1958

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine

Year adopted

2009 2009 DHA-PPQ 2002 AS+MQ; QN 2002 AS; QN 2002 CQ+PQ(14d) 0.25 mg/kg (14 days) P.f + P.v specic (Combo)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

DHA-PPQ

Year
20012010

Min
0

Median
0

Max
6.1

Follow-up No. of studies Species

28 days 14

III. Financing
14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, WHO

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

At high risk protected with ITNs With access to an ITN in household

At high risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

14 12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 80 60 40 20 10 0 2000 Positivity rate (%)

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

1.0 Cases per 1000 0.8

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

70 000 60 000 50 000 40 000 30 000 20 000 10 000 0 2000

Malaria admissions and deaths

160 140 120 100 80 60 40 20 0

Admissions

0.6 0.4 0.2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: On track for >75% decrease in incidence 20002015

WORLD MALARIA REPORT 2013 | 195

Deaths

Yemen
Saudi Arabia Oman
Conrmed cases per 1000 population/ Parasite prevalence (PP)

Eastern Mediterranean Region

Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100
Based on 2011 reported data

Insufficient data 0 00.1 0.11.0 1.010

PP

Gulf of Aden

>75 0

Based on 2011 reported data

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
10 300 000 5 350 000 8 180 000 23 830 000

%
43 22 34

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, culicifacies, sergentii

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes No Yes N/A Yes Yes 2002 2009 2001 2001 2002 2009 2009

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AS+SP AS+SP AL AM; QN CQ+PQ(14d)

Year adopted
2009 2009 2009 2009

Yes ACT is free for all ages in public sector Yes Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Yes Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

0.25 mg/kg (14 days)

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AS+SP

Year
20072011

Min
0

Median
0

Max
1.5

Follow-up No. of studies Species

28 days 6 P. f

III. Financing
18 16 14 12 10 8 6 4 2 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, Other Bilaterals, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

100 80 Cases (%) 60 40 20 2005 2006 2007 2008 2009 2010 2011 2012 0 2000 2001

Cases tested and potentially treated (public sector)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN
100 80 60 40 20 0

Suspected cases tested P. falciparum cases potentially treated with ACT

7 6 5 4 3 2 1 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%)

Proportion of malaria cases due to P. vivax

ABER (%)

2004

2005

2006

2007

2008

2009

2010

2011

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

5 4 3 2 1 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths

100 80 60 40 20 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

196 | WORLD MALARIA REPORT 2013

Deaths

Zambia
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
13 900 000 0 0 13 900 000

%
100 0 0

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. gambiae, funestus, arabiensis

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No Yes 2003 2003

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

No No

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2002 2002 2002 2002

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20052009

Min
0

Median
0

Max
6.7

Follow-up No. of studies Species

28 days 7 P. f

III. Financing
70 60 50 40 30 20 10 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, World Bank, UNICEF, WHO, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2002, DHS 2007

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

40 Cases due to P. vivax (%) ABER (%) 30 20 10

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

0 2012

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

20 16 12 8 4 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

3 500 3 000 2 500 2 000 1 500 1 000 500 0 2000 Cases per 1000

Malaria admissions and deaths (100 000)

100 80 60 40 20 0

Admissions

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: 50%75% decrease in incidence projected 20002015

WORLD MALARIA REPORT 2013 | 197

Deaths

Zimbabwe
Conrmed cases per 1000 population/ Parasite prevalence (PP)

African Region
Proportion of cases due to P. falciparum

Insufficient data no cases Very low PP 020 2040 4060 6080 80100

Insufficient data 0 00.1 0.11.0 1.010

PP

>75 0

I. Epidemiological prole
Population (UN Population Division)
High transmission (>1 case per 1000 population) Low transmission (01 cases per 1000 population) Malaria-free (0 cases) Total

2012
6 510 000 0 6 510 000 13 020 000

%
50 0 50

Parasites and vectors

Major plasmodium species: Major anopheles species: P. falciparum (100%), P. vivax (0%) An. arabiensis, gambiae, funestus

Programme phase: Control

II. Intervention policies and strategies

Intervention
ITN IRS

Policies/strategies
ITNs/LLINs distributed free of charge ITNs/LLINs distributed to all age groups IRS is recommended DDT is used for IRS

Yes/ Year No adopted

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No Yes 2009 2009 1947 2004 1997 2008 2008 2008

Intervention
Surveillance

Policies/strategies
ACD for case investigation (reactive) ACD at community level of febrile cases (pro-active) Mass screening is undertaken Uncomplicated P. falciparum cases routinely admitted Uncomplicated P. vivax cases routinely admitted

Yes/ Year No adopted

Yes Yes Yes Yes Yes

Larval control Use of larval control IPT Diagnosis Treatment IPT used to prevent malaria during pregnancy Patients of all ages should receive diagnostic test Malaria diagnosis is free of charge in the public sector ACT is free for all ages in public sector Artemisinin-based monotherapies withdrawn Single dose of primaquine (0.25 mg base/kg) is used as gametocidal medicine for P. falciparum Primaquine is used for radical treatment of P. vivax G6PD test is a requirement before treatment with primaquine Directly observed treatment with primaquine is undertaken System for monitoring of adverse reaction to antimalarials exists

Antimalaria treatment policy

First-line treatment of unconrmed malaria First-line treatment of P. falciparum For treatment failure of P. falciparum Treatment of severe malaria Treatment of P. vivax Dosage of primaquine for radical treatment of P. vivax Type of RDT used

Medicine
AL AL QN QN

Year adopted
2004 2004 2004 2004

Therapeutic ecacy tests (clinical and parasitological failure, %) Medicine

AL

Year
20062008

Min
0

Median
0.95

Max
8.1

Follow-up No. of studies Species

28 days 12 P. f

III. Financing
35 30 25 20 15 10 5 0 Contribution (US$m)

Sources of nancing

Expenditure by intervention in 2012

Insecticides & spray materials ITNs Diagnostic testing Antimalarial medicines Monitoring and evaluation Human resources & technical assistance Management and other costs
Funding source(s): Government, Global Fund, PMI/ USAID, Other Bilaterals, UNICEF, Other

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Government

Global Fund

World Bank

USAID/PMI

WHO/UNICEF

Others

IV. Coverage
100 Population (%) 80 60 40 20 0 2000 2001 2002 2003 2004

Coverage of ITNs and IRS

Source: DHS 2006, MIS 2009, DHS 2011

Cases tested and potentially treated (public sector)

100 80 Cases (%) 60 40 20 0

2005

2006

2007

2008

2009

2010

2011

2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

With access to an ITN (model) With access to an ITN (survey)

At risk protected with IRS All ages who slept under an ITN

Suspected cases tested P. falciparum cases potentially treated with ACT

12 10 8 6 4 2 0 2012

Cases potentially treated with any antimalarial P. vivax cases potentially treated with primaquine

V. Impact
100 Positivity rate (%) 80 60 40 20 0 2000 2001 2002 2003

Malaria test positivity rate and ABER

Cases due to P. vivax (%) 100 80 60 40 20 0 2000 2001 2002

Proportion of malaria cases due to P. vivax

2004

2005

2006

2007

2008

2009

2010

2011

ABER (%)

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

ABER (Micr. & RDT)

30 25 20 15 10 5 0

RDT positivity rate

Slide positivity rate

Conrmed cases (per 1000)

400 Admissions 300 200 100 0 2000 2001 2002 2003 Cases per 1000

Malaria admissions and deaths (100 000)

18 16 14 12 10 8 6 4 2 0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2004

2005

2006

2007

2008

2009

2010

2011

2012

Cases (all species)

Cases (P. vivax)

Admissions (all species) Deaths (all species)

Admissions (P. vivax) Deaths (P. vivax)

Impact: Insuciently consistent data to assess trends

198 | WORLD MALARIA REPORT 2013

Deaths

Annexes
Annex 1 Annex 2A Annex 2B Annex 3 Annex 4 Annex 5 Annex 6A Annex 6B Annex 6C Annex 6D Data completeness, 2012 Recommended policies and strategies for malaria control, 2012 Antimalarial drug policy, 2012 Funding for malaria control, 20082012 200 202 204 206

Intervention coverage estimated from routinely collected data, 20102012214 Household surveys, 20082012 Reported malaria cases and deaths, 2012 Reported malaria cases by method of conrmation, 19902012 Reported malaria cases by species, 19902012 Reported malaria deaths, 19902012 218 222 226 240 250

WORLD MALARIA REPORT 2013 | 199

Annex 1 Data completeness, 2012

Completeness score % Population Reported cases, admissions at risk and deaths % % Reporting completeness % National Active Cases Conrmed policies case laboratory diagnosed in % community detection cases % % % Interventions % Malaria nancing % Government contribution %

WHO Region

Country/area

Country classication phase1

200 | WORLD MALARIA REPORT 2013

72 64 79 66 86 72 73 73 64 44 76 60 32 86 56 74 61 51 81 98 69 52 57 82 71 66 72 58 42 49 96 89 63 61 92 61 76 75 90 85 74 94 100 67 85 64 91 84 86 72 68 83 83 100 100 100 100 100 100 100 67 100 100 100 100 33 100 100 100 100 33 100 100 33 33 100 100 100 100 100 100 100 67 100 100 33 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 94 80 84 38 98 100 100 45 71 73 80 73 84 100 96 100 82 78 89 100 89 69 64 67 80 67 69 71 88 73 84 100 82 78 100 20 80 49 80 100 89 100 93 78 91 100 100 100 100 100 71 56 20 60 60 80 80 40 60 100 60 0 40 80 40 60 60 60 40 60 100 80 60 40 100 100 20 80 40 0 0 80 80 60 80 100 40 40 80 80 80 40 80 80 100 80 60 80 40 20 20 20 60 80 50 71 25 63 50 17 8 33 100 42 29 100 83 100 58 50 67 100 46 50 54 83 63 42 38 54 75 100 100 33 54 100 25 71 100 75 100 96 100 0 42 100 100 100 100 100 0 100 0 100 100 100 50 0 100 33 0 100 0 50 0 0 83 100 83 0 0 100 50 0 100 0 50 100 100 0 100 100 50 50 17 100 100 67 100 0 100 100 0 100 0 50 0 44 28 22 0 0 6 0 33 33 0 0 17 33 0 67 0 100 11 0 0 78 0 0 22 0 0 100 100 0 0 100 11 56 67 67 11 22 100 0 67 94 100 100 61 56 72 96 100 100 100 98 100 89 92 78 91 91 28 100 80 98 100 100 85 100 100 98 94 96 100 100 100 77 63 48 100 76 100 81 84 100 76 96 100 98 100 94 100 72 87 61 84 100 93 92 84 96 98 20 100 100 100 100 100 100 100 82 70 100 100 55 100 100 100 100 52 100 100 97 100 100 100 100 100 100 79 0 100 100 100 100 100 100 94 100 45 100 100 100 100 100 100 60 100 100 100 100 20 100 80 100 100 100 93 100 100 100 58 100 40 87 27 33 100 27 100 100 33 100 100 100 100 40 100 100 100 100 100 0 0 100 100 100 0 100 100 93 100 100 100 87 100 100 100 25 100 100 100 100 100 100 100 100 50 33 100 100 33 50 50 67 50 33 17 17 100 0 0 33 33 83 100 67 33 17 0 100 67 50 100 0 100 50 100 0 100 67 50 100 100 100 0 67 100 100 100 50 50 100 50 50 50 100 67

African

Elimination Control Control Control Control Control Control Pre-elimination Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control

Region of the Americas

Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cabo Verde Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali Mauritania Mayotte Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia Zimbabwe Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador

Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Control Pre-elimination Pre-elimination Control Control Pre-elimination Elimination Control Pre-elimination

WHO Region

Country/area

Country classication phase1

Completeness score %

Population Reported cases, admissions at risk and deaths % %

Reporting completeness %

National Active Cases Conrmed policies case laboratory diagnosed in % community detection cases % % %

Interventions %

Malaria nancing %

Government contribution %

Region of the Americas

Eastern Mediterranean

European

South-East Asia

Western Pacic

El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of ) Afghanistan Djibouti Iran (Islamic Republic of ) Pakistan Saudi Arabia Somalia South Sudan 2 Sudan Yemen Azerbaijan Kyrgyzstan Tajikistan Turkey3 Uzbekistan Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

Pre-elimination Control Control Control Control Control Pre-elimination Control Control Pre-elimination Control Control Control Control Control Elimination Control Elimination Control Control Control Control Elimination Prevention of re-introduction Elimination Elimination Prevention of re-introduction Control Pre-elimination Pre-elimination Control Control Control Control Elimination Control Control Control Control Control Pre-elimination Control Control Elimination Control Control Control

87 37 92 86 71 82 94 83 88 100 81 68 68 83 72 90 61 91 80 64 68 81 95 100 96 99 100 95 88 89 72 79 66 84 93 91 91 89 76 98 88 59 90 68 87 81 84

100 100 100 100 100 100 100 100 100 100 100 100 100 100 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

100 44 73 56 96 60 100 87 60 100 100 73 31 100 87 73 18 86 49 36 80 76 100 100 100 95 100 100 58 61 13 100 87 60 77 58 80 96 64 100 83 40 69 83 84 49 67

80 0 100 60 20 100 80 40 40 100 40 20 20 100 100 80 80 80 80 100 100 80 100 100 100 100 100 80 80 80 80 80 0 80 100 80 80 80 80 100 80 80 100 0 100 80 80

100 100 100 100 100 100 100 100 92 88 88 25 100 58 17 29 100 100 92 100 100 100 92 100 100 96 100 100 83 100 100 96

0 100 100 100 0 100 100 100 100 0 100 100 50 50 67 0 33 100 50 100 50 100 100 100 100 50 100 0 100 50 100 100

0 100 78 100 100 72 100 100 83 100 44 83 61 67 11 0 39 100 0 0 0 22 78 50 11 61 100 0 100 39 0 17

96 60 82 88 91 62 98 80 77 100 50 98 88 98 100 94 98 92 100 100 84 100 100 100 100 100 100 100 100 85 77 82 73 73 100 100 100 100 100 73 76 100 96 100 100 100

80 6 100 100 100 100 80 100 100 100 36 36 100 100 76 80 48 80 100 91 100 100 90 100 100 100 100 100 80 80 100 100 94 100 100 100 100 100 85 100 80 30 100 0 100 100 94

83 60 100 100 0 100 100 100 100 100 100 80 100 100 100 100 40 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 87 100 100 100 100 100 100 100 100

67 0 67 83 0 100 100 50 100 100 83 0 50 0 50 100 17 100 100 17 100 100 75 100 75 100 67 100 100 100 33 50 100 100 100 100 100 33 83 100 67 50 100 100 83

WORLD MALARIA REPORT 2013 | 201

Country classication as of December 2013 In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region 3 Country did not submit a report for 2012 Question does not appear on the form for that country Egypt, Oman and the Arab Syrian Republic are in Prevention of reintorduction classication phase but do not appear in the list.

Annex 2A Recommended policies and strategies for malaria control, 2012

insecticide-treated mosquito nets ITNs/ LLINs are distributed to all age groups N N N Y Y N N N N Y Y Y N Y Y Y Y Y Y N Y Y Y Y N N Y Y N N Y N N Y N Y Y Y N/A Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N Y Y N Y Y Y Y N Y N Y Y N Y Y N Y Y Y Y Y Y N N Y Y Y Y Y N Y Y Y N Y N N Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N N Y Y ACT policy adopted Patients of all ages should get diagnostic test Malaria diagnosis is free of charge in the public sector Indoor residual spraying Treatment Malaria in pregnancy IPTp used Seasonal to prevent malaria malaria chemo during prevention pregnancy (SMC or IPTc) is used

WHO Region

Country/area

ITNs/ LLINs are distributed for free

202 | WORLD MALARIA REPORT 2013

N Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y ITNs/ LLINs IRS is the DDT is used distributed primary for IRS through vector mass control campaigns intervention to all age groups Y N N Y N Y Y N Y Y Y Y Y N Y N N Y N N Y N N Y N Y Y N Y Y N Y Y N N Y Y Y Y Y N Y Y N Y Y N N N N Y Y Y Y Y N Y Y N Y N N Y Y N Y Y N Y Y N Y Y N Y Y N Y N N Y Y Y Y Y Y N Y N Y Y N Y Y N Y Y N Y Y N Y Y N N Y Y Y Y Y Y Y N Y Y N RDTs used at Pre-referral Single dose of Primaquine G6PD test is Directly community treatment primaquine is used for recommended observed level with quinine (0.25mg base/ radical before treatment or artemether kg) is used as treatment treatment with IM or gametocidal of P. vivax with primaquine artesunate medicine for cases primaquine is suppositories P. falciparum undertaken Y Y N Y N Y Y Y N Y Y N N N N N N N N N N Y N N N N Y N N N N N Y N Y Y Y Y Y N N Y Y N N N N N Y N N N N N Y N N N N N Y N N N N Y Y N N N N N N N N N N N Y Y N Y N N Y Y N N N N N N N Y Y N N Y Y Y N N N N Y Y N N N N N Y N N N N N Y Y Y N N N N Y N N N N N N Y N N N N Y Y N N N Y Y N Y Y N Y Y Y Y Y Y N Y N Y N N N N Y N N N N Y Y N Y Y Y N N N N Y Y Y N N N N N Y Y Y N N N Y Y N N Y Y N N N N N Y Y Y N Y Y Y Y Y Y Y N N Y Y Y N Y Y Y Y Y Y Y N N Y Y N N Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y N N N N N N N N N Y Y Y Y N/A N/A Y Y Y N/A N/A Y N/A Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y N N Y Y Y N N Y N Y Y Y Y N N Y Y N N N N N N N N Y Y N Y Y N Y N N N N Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N Y Y N N N Y Y Y Y Y Y Y Y N/A N/A N/A N/A N/A N/A N/A N/A N/A N N Y N N N N Y N N N N N N N N N N N N N N Y N N Y N N N N Y N N N N Y N/A N/A N/A N/A N/A N/A N/A N/A N/A

African

Region of the Americas

Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali Mauritania Mayotte Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania United Republic of Tanzania (Mainland) United Republic of Tanzania (Zanzibar) Zambia Zimbabwe Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador

WHO Region ITNs/ LLINs are distributed to all age groups ACT policy adopted Patients of all ages should get diagnostic test Malaria diagnosis is free of charge in the public sector IPTp used Seasonal to prevent malaria malaria chemo during prevention pregnancy (SMC or IPTc) is used

Country/area

insecticide-treated mosquito nets

Indoor residual spraying

Treatment

Malaria in pregnancy

ITNs/ LLINs are distributed for free

Eastern Mediterranean

European

South-East Asia

WORLD MALARIA REPORT 2013 | 203

Western Pacic

French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of ) Afghanistan Djibouti Iran (Islamic Republic of ) Pakistan Saudi Arabia Somalia South Sudan1 Sudan Yemen Azerbaijan Kyrgyzstan Tajikistan Turkey Uzbekistan Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

N Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y N N Y Y Y Y N Y Y Y Y Y Y Y N Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y

ITNs/ LLINs IRS is the DDT is used distributed primary for IRS through vector mass control campaigns intervention to all age groups Y Y N Y Y N N Y N Y N N Y Y N Y N N Y Y N N Y N N Y N Y N N N N Y Y N Y Y N Y Y N Y N N Y N Y N Y Y N Y Y N Y Y N Y Y N Y N Y N Y N Y N Y N Y Y N Y Y N Y N Y Y Y Y Y N Y Y N Y Y N Y N Y Y N Y Y N Y N N Y Y N Y Y N N Y Y N N Y N N N Y N Y N N Y Y N Y N N Y Y N Y N Y N N/A N/A Y N/A N/A N/A N/A N/A Y Y Y Y Y Y Y Y Y Y Y Y Y N/A Y N/A Y Y N/A Y Y Y Y Y Y Y Y Y Y Y Y Y N/A Y Y Y Y N/A Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y N Y Y Y Y Y Y N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N N/A N/A N/A Y N N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Y N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N N N N N/A N/A N/A N/A N/A

RDTs used at Pre-referral Single dose of Primaquine G6PD test is Directly community treatment primaquine is used for recommended observed level with quinine (0.25mg base/ radical before treatment or artemether kg) is used as treatment treatment with IM or gametocidal of P. vivax with primaquine artesunate medicine for cases primaquine is suppositories P. falciparum undertaken N N N Y Y N Y Y N N N N Y Y N N N N Y Y N N N Y Y N N N N Y Y N Y Y N Y Y N Y N N Y Y N Y N N N Y N Y Y Y Y Y N Y Y Y Y Y N N N N Y Y N Y Y N Y Y N N N N N N N Y Y N Y N Y Y Y Y N Y N Y N N Y N N N N N Y N N N N Y Y N Y N N Y Y Y N Y N Y Y Y N Y Y Y N Y N Y N Y Y Y N Y Y Y N Y N N N N Y Y N N N Y N Y Y Y Y Y N N Y Y Y Y N N Y Y Y Y N N Y Y Y Y Y Y Y N Y Y N Y Y Y N Y N N Y N N N Y N N N N Y N Y Y N N N Y N N Y Y Y N Y Y N Y Y Y Y Y N N N Y N Y Y N Y Y N Y Y N Y N Y Y N Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y

ACT, artemisinin-based combination therapy; DDT, dichlorodiphenyltrichloroethane; IM, intramuscular; IPTc, intermittent preventive treatment for children; IRS, indoor residual spraying; ITN, insecticide-treated mosquito net; LLIN, long-lasting insecticidal net; N/A, not applicable; RDT, rapid diagnostic test; SMC, seasonal malaria chemoprevention (Y) = Actually implemented (N) = Not implemented (N/A) = Not applicable () = Question not answered 1 In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

Annex 2B Antimalarial drug policy, 2012

P. falciparum Uncomplicated unconrmed AL AL AL AL;AS+AQ AS+AQ AL AS+AQ AL AL;AS+AQ AL AS+AQ AS+AQ AS+AQ AS+AQ CQ+SP AL AS+AQ AL AS+AQ AS+AQ AL AL AS+AQ AS+AQ AL AS+AQ AS+AQ AL AL AL AL;AS+AQ AL AS+AQ AS+AQ AS+AQ AL;AS+AQ AL QN QN QN QN QN QN AM+CL;AS+CL AS CQ;QN QN QN AL AL AL AL;AS+AQ AS+AQ AL AS+AQ AL AL;AS+AQ AL AS+AQ AS+AQ AS+AQ AS+AQ AS+AQ AL AS+AQ AL AL;AS+AQ AS+AQ AL AL AS+AQ AS+AQ AL AL;AS+AQ AL;AS+AQ AL AL AL AL;AS+AQ AL AS+AQ AL;AS+AQ AL;AS+AQ AL;QN+CL;QN+D AL AL;AS+AQ AL QN QN QN QN QN QN AM;QN AM;QN AM;QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN QN AM;AS;QN AS QN QN AM;QN QN QN QN QN SP(IPT) SP(IPT) CQ+PG SP(IPT) CQ SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) CQ+PG CQ+PG SP(IPT) SP(IPT) Uncomplicated conrmed Severe Prevention during pregnancy Treatment P. vivax

WHO Region

Country/area

204 | WORLD MALARIA REPORT 2013

AL AS+AQ AL AL AL AS+AQ AL AL AL CQ+PQ AS+MQ+PQ AL+PQ(1d);AS+MQ+PQ(1d) AL CQ+PQ(1d) CQ+PQ(3d) AL CQ+PQ(1d) SP(IPT) SP(IPT) SP(IPT) SP(IPT) CQ CQ+PQ CQ AL AL+PQ;CQ+PQ CQ+PQ CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(7d);CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(7d);CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d)

African

Region of the Americas

Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali Mauritania Mayotte Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania Mainland Zanzibar Zambia Zimbabwe Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador

WHO Region P. falciparum Uncomplicated unconrmed Uncomplicated conrmed Severe Prevention during pregnancy Treatment P. vivax

Country/area

Eastern Mediterranean

European

South-East Asia

Western Pacic

French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of ) Afghanistan Djibouti Iran (Islamic Republic of ) Pakistan Saudi Arabia Somalia South Sudan1 Sudan Yemen Azerbaijan Kyrgyzstan Tajikistan Turkey Uzbekistan Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu

CQ AS+SP CQ AS+SP AS+AQ AS+SP AS+SP AS+SP CQ CQ AL CQ AL

AL;AT+PG;QN+D CQ+PQ(3d) AL+PQ(1d) CQ+PQ(1d) CQ+PQ(1d) CQ+PQ CQ+PQ AL AL AS+MQ AL+PQ AS+MQ+PQ AS+SP AS+SP AS+SP AS+SP AS+SP AS+SP AS+AQ AS+SP AS+SP AS+SP AL AL AL AS+SP+PQ AS+AQ;DHAPP+PQ AL;AM;AS+MQ;DHAPPQ;PQ AL+PQ AL+PQ AS+MQ AL AS+MQ;DHAPPQ+PQ ART+NQ;ARTPPQ;AS+AQ;DHAPPQ AL AS+MQ AL AL+PQ AL AL

CQ QN QN+CL MQ AS AM;QN AM+QN QN AS;QN+D AS;QN AM;AS;QN AS;QN AM;AS;QN AM;QN AM;QN AS;QN QN AM;QN AM;QN AM;AS;QN AM;AS;QN AM;AS;QN QN QN AS;QN AM;AS;QN AM;QN AM;AS;PYR AS+AL QN+T AM;AS QN+T AL;AS QN

QN+D SP(IPT) SP(IPT) SP(IPT) SP(IPT) SP(IPT) CQ CQ(weekly)

CQ+PQ CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ CQ+PQ(7d) CQ+PQ(7d);CQ+PQ(14d) CQ+PQ CQ+PQ CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(8w) CQ+PQ(14d&8w) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) AS+AQ+PQ AL CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) AS+AQ;DHAPP+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) CQ+PQ(14d) DHAPPQ CQ+PQ(8d) CQ+PQ(14d) CQ+PQ(14d) AL+PQ CQ+PQ(14d) CQ+PQ(14d) AL+PQ(14d) AL+PQ(14d)

IPT, intermittent preventive treatment

WORLD MALARIA REPORT 2013 | 205

AL=Artemether-lumefantrine AS=Artesunate D=Doxycycline PG=Proguanil QN=Quinine AM=Artemether AT= Atovaquone DHA=Dihydroartemisinin PPQ=Piperaquine SP=Sulphadoxine-pyrimethamine AQ=Amodiaquine CL=Clindamycline MQ=Meoquine PQ=Primaquine T=Tetracycline ART=Artemisinin CQ=Chloroquine NQ=Naphroquine PYR=Pyronaridine 1 In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

Annex 3 Funding for malaria control, 20082012

Contributions reported by donors Global Fund
3

WHO Region Contributions reported by countries DFID Government Global Fund The World Bank PMI/USAID Other bilaterals WHO UNICEF Other contributions5 PMI/USAID The World Bank

Country/area

Year

European Union

African

Algeria

Angola
4 4 4 4

Benin
4 4

206 | WORLD MALARIA REPORT 2013

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Botswana

Burkina Faso

Burundi

Cabo Verde

Cameroon

Central African Republic

Chad

Comoros

Congo

Cte d'Ivoire

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2008 2009 2010 2011 2012 2010 2011 2012 2009 2010 2011 2012
4

9 872 558 9 614 770 11 200 000 7 070 600 6 345 919 214 400 21 700 000 5 467 432 5 533 925 7 283 872 14 800 000 43 800 000 10 500 000 38 000 000 9 623 263 4 532 059 15 500 000 6 149 217 1 018 766 364 436 6 046 764 9 610 844 1 635 796 66 200 000 1 551 732 2 294 055 962 051 723 324 3 578 002 4 644 509 22 700 000 4 208 387 264 709 232 885 4 256 900 1 106 246 127 142 11 900 000 1 262 613 1 035 856 16 200 000 58 300 000 14 300 000 17 900 000

18 800 000 22 900 000 34 300 000 30 600 000 30 200 000 17 700 000 18 100 000 20 600 000 18 500 000 17 900 000 1 500 000 4 500 000 1 500 000 4 500 000

205 930 261 722 240 569 1 770 597 1 829 615 597 208 3 662 724 4 170 093 1 880 016

2 700 279 1 455 842

1811684 17126365 32321720 31477010 98151555 17525978 15676687 66637986 57415819 764627 2042222 200000 1500000 1308890 876647 709607 2250933 1921908 58662 554094 4508617 6482938 11380472 46000 147422 22000 401316 451098 707795 604871 14006863 8545999 975590 5150943 3178626 45000 42000 34000 34000 371463 953930000 600000000 2678 24158 114215 225621 6956815 34964064

0 0 0 0 0 17950321 13873496 2135717 376990 327593 1130708 18060813 9011888 813399 67991119 1458620 2546429 4834000 4683029 5185632 13625189 8661526 4382754 0 0 11506022 8529662 1573566 55336850 11655745 2294055 0 962050 481345 5262314 5215000 264708 290612 4610020 773425 3982625 4740367 27941028

5547000 6527000 0 5073238 0 0 0 0 0 0 0 0 600000 600000 600000 0 0 0 0

18500000 18925000 18700000 30614000 30750000 13887000 13800000 13800000 21000000 16100000 0 4210524 2072216 2698000 6000000 6000000 5988000 8000000 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 1171250 250000 33879 64530 34903 16600 8856727 2720000 1031803 0 3300000 0 4500000 74535 307748

12000 10000 17000 33000 439000 660000 660000 108966 16940 99027 29500 45003 12771 266540 94294 58500 74327 300000 300000 264625 313300 449000 100000 100000 100000 100000 77083 146250 104000 104000 137000 2605303

105893 248540 123571 75895 1816055 140253 14000 1817914 387300 708425 1540000 33400 178043 34981 1196800 1000644 10000 550000 219747 30000 65000 11656 69012

1000000 0 0 0 0 70000 94000 2602730 0 0 0 0 0 0 0 0 3958 6682000 0

WHO Region Contributions reported by donors Global Fund PMI/USAID The World Bank DFID3 Government Global Fund PMI/USAID Other bilaterals WHO UNICEF Other contributions5 European Union Contributions reported by countries

Country/area

Year

African

Democratic Republic of the Congo

Equatorial Guinea

Eritrea

Ethiopia

Gabon
4 4

Gambia

Ghana

Guinea

Guinea-Bissau
4 4

Kenya

4 4

Liberia

Madagascar

WORLD MALARIA REPORT 2013 | 207

4 4

Malawi

2008 2009 2010 2011 2012 2008 2009 2010 2011 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

18 200 000 70 900 000 44 300 000 2 106 190 105 000 000 6 305 881 3 445 774 5 371 664 2 599 520 4 754 718 206 600 21 400 000 4 908 106 8 229 050 3 138 583 121 000 000 28 300 000 51 900 000 23 800 000 1 338 162 3 891 808 871 083 5 683 473 5 921 546 8 960 101 7 119 980 5 393 233 10 500 000 27 000 000 30 600 000 24 600 000 1 002 592 12 400 000 20 100 000 1 526 060 1 644 833 6 965 345 2 922 931 255 313 19 000 000 26 400 000 39 100 000 12 200 000 10 900 000 8 863 680 345 575 8 229 609 5 198 534 12 200 000 15 100 000 12 100 000 54 500 000 18 400 000 25 500 000 15 000 000 3 721 540 5 492 126 45 000 000 2 473 270

9 325 000 16 200 000 22 200 000 35 700 000 37 000 000 19 800 000 22 500 000 33 500 000 41 400 000 41 500 000 17 000 000 21 500 000 33 000 000 30 400 000 30 800 000 2 495 000 9 985 000 10 000 000 19 800 000 24 800 000 39 100 000 36 400 000 35 900 000 12 400 000 13 400 000 16 800 000 13 000 000 12 000 000 17 100 000 21 400 000 33 100 000 28 700 000 26 700 000 20 100 000 20 800 000 27 900 000 26 500 000 24 200 000

5 525 751 10 900 000 11 800 000 880 201 349 947 165 641 2 379 226 708 817 655 112

25 900 000 361 860 15 600 000 8 566 783 15 500 000 19 900 000 11 300 000 17 400 000

2000000 2000000 296443 296443 303835 300000 717569 3456244 6144036 1293523 1400769 517767 1025550 529610 613412 597812 269583 6214286 6533333 6663582 7700154 9687 154564 3948 50880 8000 103440000 79269000 32566 822742 2741417 60118 19387 19000 110504 90900 95000 5985915 4482759 8453947 720000

18188352 4071980 23044824 33775293 64140129 8245229 4756207 5031797 3425062 4792642 3312520 19155845 10722859 11157713 18990619 81586570 107128416 32231572 42424919 450693 5683474 5921546 8960101 8835940 4107095 10544980 18363180 30649705 53169328 34668998 13424707 3914541 1705505 1545699 1279343 6809770 1070641 18177 37543798 25921567 6347301 990100 8118208 16400946 14243081 5814063 25329554 53367022 19557627 31371350 5492126 9720000

The World Bank 43000000 11101283 10262916 58805836 73719913 300000 0 0 0 0 10090000 9900000 0 0 0 0 4000000 1283389 0 400000 0 1181250 1181250 0 0 0 0 3400000 0 0 0 0 0 0 7240000 15580000 15580000 18000000 34930000 165000 0 0 0 0 0 6587000 19700000 31000000 0 0 0 0 16900000 17300000 34000000 34000000 27010000 10000000 0 0 0 0 19838000 37652822 30829000 12500000 61375 12000000 12000000 12000000 17000000 12753000 16700000 33900000 28742000 16000000 18000000 27000000 21600000 596182 36765988 45000 4759000 5673954 8047523 0 0 0 0 164372 0 0 45000 113000 100000 250000 89000 119149 1000000 0 0 250000 581 6773166 0 0 99750 0 500000 17975039 50000 0 0 578000 47250 51000 3240000 45104 86895 520000 15000 100000 0 0 0 280000 210960 171357 0 72500 380500 40000 134306 200000 290000 150000 300000 200000 250000 109000 51500 49500 41060 146000 100000 100000 68000 124135 87584 5786287 19675 73333 638691 100532 418861 153000 111315 100000 50000 70000 5662078 5365009 2271712 2389964 5584965 254037 105000 0 0 0 4200000 5000000 1297858 27243 17000 65000 2143 4800 1200000 939300 101053 2000000 79490 432000 819553 15736 329305 486579 425541 7238 436945 30000 226743 304750 0 3852552 1103644 668216 422624 875717 500000 50000 50000 12575325 4759000 6787000 0 0 0 0 7624294 0 0 0 0 0 300000 300000 98733 16100000 7911545 6000000 2375040 0 0 0 0 500000 11131200 500000 210000 0 0 0 0 720000

Annex 3 Funding, 20082012 (continued)

Contributions reported by donors Global Fund
3

WHO Region Contributions reported by countries DFID Government Global Fund PMI/USAID WHO UNICEF PMI/USAID The World Bank

Country/area

Year

European Union

African
4

Mali

Mauritania

208 | WORLD MALARIA REPORT 2013

4 4 4 4 4 4 4 4 4 4 4 4 4

Mozambique

Namibia

Niger

Nigeria

Rwanda

Sao Tome and Principe

Senegal

Sierra Leone

South Africa

Swaziland

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

4 233 040 4 330 851 1 342 027 541 854 500 223 11 600 000 520 865 23 000 000 7 683 006 29 700 000 412 016 3 797 710 1 165 287 1 298 393 1 243 974 12 300 000 17 500 000 2 964 287 3 300 846 441 165 16 300 000 224 000 000 1 056 110 29 900 000 123 000 000 19 300 000 42 500 000 20 500 000 17 000 000 26 000 000 2 424 782 75 857 1 060 100 1 571 589 5 839 346 14 300 000 2 507 790 1 118 536 20 700 000 4 840 240 2 794 509 799 743 13 800 000 2 991 631 294 218 2 607 294 1 377 144 1 116 084

16 500 000 21 300 000 31 600 000 33 000 000 26 500 000 24 400 000 38 800 000 39 100 000 33 000 000 29 800 000 10 300 000 17 400 000 25 400 000 51 100 000 55 900 000 16 700 000 16 700 000 18 200 000 18 700 000 18 100 000 21 400 000 18 700 000 26 400 000 24 500 000 23 800 000

46 600 1 187 319 843 430 1 047 934 15 500 000 67 900 000 30 900 000 97 700 17 716 4 030

2 956 531 2 573 946 1 378 107 2 526 054 2 479 466 9 768 276 18 200 000 15 400 000 1 093 408 7 528 957

2737186 1259872 33941 11000000 170000 1690211 2411088 2731460 4466719 4500000 900000 900000 700000 500000 2115926 14324952 200000 6493506 2493181 1740000 500000 54267 303802 74583 52941 128502 176000 449813 155764 118000 180552 198586 1198629 404235 1231395 24757142 27142857 25064907 13162365 24291216 964009 1002947 685739

6703715 5214224 7120975 2858296 0 350000 0 0 4826069 2267472 1362347 589694 926804 28057121 972351152 529956 225901 15353110 42019322 61357535 73332766 83083666 12884983 40117815 514393 1699172 782254 1521822 926494 11436555 2531265 9620506 21567732 5126487 4884763 5241344 11763088 2197637 1924448 1376584

The World Bank 1749540 847617 0 0 0 0 0 0 0 1773423718 772219032 0 60000 52358702 17500000 5492349 3083332 40000 126000 350000 0 459294 5141 0 0 0 0 8932000 8932000 11184211 4737692 5298930 0 0 0 0 0 0 0 0 0 38000 11900000 16000000 18000000 43000 43600000 17000000 0 0 0 0 0 490000 14512634 17329326 21758440 0 0 0 0 292000 50535 1575926 92000 0 52584 1000 25000 0 0 0 0 0 0 15000 840196 4500 1058500000 4500 586204 16000 816535 306321 37247310 20750000 35000 0 63165 10000 59965 5000 38163 3000 54428 3000 47962 3000 394552 288302 97987 372518 778590 26413 19673 137255 165625 43261 286406 430000 2812 100000 0 0 0 0 0 0 0 0 0

Other bilaterals 2806479 965774 291162 0 0 0 0 194428 556900 2235276 18210725 1700 1717 30315 0 2000 6793567 10478 8571428 254869 0 0 0 0

Other contributions5 6550000 3116725 894577 319404 1000000 0 0 0 0 0 2374736 0 0 2895752 10229555 17678415 18908794 1000000 1000000 1172611 0 1022740 50000 0 0 0 0

WHO Region Contributions reported by donors Global Fund PMI/USAID The World Bank DFID3 Government Global Fund The World Bank PMI/USAID WHO UNICEF Other contributions5 European Union Contributions reported by countries

Country/area

Year

African

Togo

Uganda

United Republic of Tanzania

4 4

Mainland
4 4

Zanzibar

Zambia

Zimbabwe

Region of the Americas

4 4 4 4 4 4 4 4

Argentina

Belize

Bolivia (Plurinational State of )

Brazil

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Colombia

WORLD MALARIA REPORT 2013 | 209

Costa Rica

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

5 026 694 4 525 903 8 447 243 21 000 000 239 270 6 335 768 41 000 000 31 100 000 9 465 369 83 100 000 56 900 000 58 600 000 50 400 000 42 500 000 15 200 000 1 770 569 1 397 265 1 530 146 1 363 902 2 116 856 1 773 184 1 525 890 3 423 745 4 858 206 5 509 723 7 641 225 10 800 000 4 615 661 3 133 235

26 400 000 30 700 000 29 300 000 35 300 000 34 600 000 42 500 000 59 900 000 57 600 000 49 900 000 48 000 000

653 644 407 279 914 725 1 249 609 2 333 036 59 400

223896 223896 225535 7267857 838226415 616085000 838226415 340000000 21830362 260823 553167 29467 29333 29267 0 1250 1900000 848745 414580 279788 402975 1302500 1650000 1000000 1200000 906000 1082700 1082700 1082700 170494 148621 169184 215224 300000 1593484 1699130 1700145 1110097 787966 71468113 67952169 64436226 78565078 61378194 17800000 20500000 21788036 20157754 22898987 6720000 6240000 4845000 5270000 5350000

2442924 592434 884398 155963673 56141986 83701649 46300000 46300000 105217601 17701499 18031872 1705252 2401665 1311590 808088 0 3817916 986834 12335725 5282152 12105399 1100000 2800000 24000000 10063628 19069239 0 0 0 0 0 550000 2482576 1400635 1909295 0 4884938 10361470 17851837 0 2000000 1000000 9175784 5347470 5959287 0 0 0 0 0

14197371 0 0 0 25000000 25000000 0 0 0 0 0 0 0 0 5000000 0 29401235 3612027 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 21752000 21600000 35000000 34366813 33000000 34000000 34000000 52000000 75000 165480 3020800 2937375 3133000 5104000 4123200 14888000 14700000 25600000 24000000 24000000 200000 0 1000000 12000000 12000000 0 32000 29500 200000 200000 200000 177000 72000 65000 65000 227000 30000 49694 120000 120000 120000 120000 120000 0 0 0 0

Other bilaterals 3788783 954226 2688 14090 0 40000 1000000 1000000 43401000 0 0 0 0 0 43953 138140 1850000 300000 500000 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20573 3261 1489 23832 88490 317816 50000000 50000000 300000 70000 360000 0 30000 67743 52388 130000 398000 380000 130000 130000 79000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52000 52000 45000 0 0 0 0 341805 92523 8674 0 2545396 139313 0 0 108552 198000 221000 4898 550847 212570 100000 75000 50000 25000 18250 42000 0 0 0 0 40000 25000 50000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 92378 8747 0 0 0 0 21564 19372 2281500 7200000 7215019 7161185 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

70000 0 0 0

Annex 3 Funding, 20082012 (continued)

Contributions reported by donors Global Fund
3

WHO Region Contributions reported by countries DFID Government Global Fund The World Bank PMI/USAID Other bilaterals WHO UNICEF Other contributions5 PMI/USAID The World Bank

Country/area

Year

European Union

Region of the Americas

Dominican Republic

Ecuador
4 4

210 | WORLD MALARIA REPORT 2013

4 4 4 4 4 4

El Salvador

French Guiana, France

Guatemala

Guyana

Haiti

Honduras

Mexico

Nicaragua

Panama

Paraguay

Peru

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2010 2011 2012
4

1 396 348 1 207 483 1 423 587 1 475 716 2 701 041 1 939 571 1 690 157 3 325 400 1 343 648 8 917 396 2 821 516 141 763 1 329 110 573 070 612 352 425 717 3 322 684 1 000 764 18 400 000 4 516 089 968 258 956 414 1 425 920 572 711 1 288 990 793 799 2 505 734 2 086 863 2 331 302 803 339

2361111 2337714 5194215 2153141 2068141 3941711 2428604 2327187 3314143 1957708 1920000 3057500 3513000 3688650 3380000 10558243 5487457 320840 341775 661500 62840 1075952 2085000 576434 649579 939438 990876 295570 21097815 22875348 23140145 23741789 24285354 457751 429381 320053 439258 1300000 1459724 2152435 3798322 911621 3944353 4263661 3245670 1813409 2115436 13000000 70768247 109318163

0 185772 2126483 1823682 2323120 220000 400000 531945 327863 150820 0 0 0 0 0 0 0 1849992 0 0 3596431 2780074 337620 799527 2085000 316567 1100908 1158468 842438 970940 0 0 0 0 0 600000 2015344 731600 2032089 1747908 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

54174 14503 150031 46155 0 82000 0 0 0 0 0 0 0 0 10561 119000 140000 110000 120000 150000 82383 55000 90964 80278 58936 0 0 0 0 33674 43163 41663 0 0 0 0 23951 0 125000 200000

0 0 0 0 20776 100000 0 0 0 0 0 0 0 0 0 25000 0 0 34000 10000 4000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

39303 58538 0 0 0 80000 0 0 0 0 0 0 25000 10000 10000 14000 20000 19522 22522 29670 11856 14546 0 0 0 0 0 35000 5433 6001 0 0 36640 15209 10000 13000 5635

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16173 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 14000

WHO Region Contributions reported by donors Global Fund PMI/USAID The World Bank DFID3 Government Global Fund The World Bank PMI/USAID Other bilaterals WHO UNICEF Other contributions5 European Union Contributions reported by countries

Country/area

Year

Region of the Americas

Suriname

Venezuela (Bolivarian Republic of )

4 4 4 4

Eastern Mediterranean

Afghanistan

Djibouti
4 4 4 4

Iran (Islamic Republic of )

Pakistan

Saudi Arabia

Somalia

South Sudan 7
4 4

Sudan

Yemen

European

Azerbaijan

WORLD MALARIA REPORT 2013 | 211

Kyrgyzstan

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

875 248 1 736 185 835 305 710 949 355 313 8 141 152 20 900 000 3 105 472 1 161 128 11 800 000 1 244 752 148 961 146 471 112 748 44 923 2 797 683 374 798 2 226 429 2 350 551 8 256 054 1 642 417 6 873 870 3 390 454 1 185 971 19 000 000 3 784 480 1 959 263 5 223 275 2 594 870 22 100 000 22 100 000 13 400 000 7 790 017 21 800 000 27 000 000 12 400 000 17 100 000 18 900 000 14 900 000 51 800 000 1 295 872 1 786 084 887 980 280 163 548 346 1 013 420 172 070 1 166 939 1 016 966 496 411

69 200 3 871 000 2 685 000

2 851 587 1 507 012 94 200

93 200 1 157 623 657 603 1 548 016 253 713

2446124 12089014 1938592 790292 79442 84745 84745 1050000 7500000 8000000 9690000 12500000 8000000 300000 500000 28203753 28850000 28000000 26357710 29000000 24230 46321 63250 120000 530000 10573479 10993899 12810941 26724830 26709969 2465870 1806742 1594698 1012076 1136852 2145369 1971844 3842152 3738835 5000968 68500 70000 70000 70000 70000

547672 0 0 0 0 7785080 6372330 7928628 7535557 10613985 206939 206939 48527 664575 3372294 2326659 1474935 5238195 2500000 4500000 3390454 1185971 15231843 0 0 0 0 6607321 6863696 8436831 5685340 11904217 17395819 16117077 15361962 38496269 3700680 15869166 15829743 19418808 38398132 4185533 4401240 3482712 880150 8908540 0 1423641 1692999 610905 462920 647245 546245 1394485 1114124 850061

0 0 0 0 0 0 0 26810 420117 8413 0 0 0 0 0 41360 0 0 0 0

100000 0 0 0 0 415335 802371 0 3000000 9600000 39416 0 0 0 0 0 0 0 0 0

0 0 0 0 104109 22813 65236 0 0 0 81127 8586562 0 0 363495 1680907 250000 1199999 4564902 9084589 5807093 0 0 0 0 0 0 0 0 0 0

0 0 211689 1186740 414619 30000 116291 2040 55782 50000 25000 13000 12500 12500 215947 31000 36000 99000 99000 85000 101650 65000 86000 103400 350000 400000 750000 2934000 39416 0 0 114575 641921 200000 475000 474037 240000 65000 35000 35000 35000 35000 0 0 0 0 0

0 0 0 0 0 2824 142000 842791 3452658 13983001 1259562 553635 494000 0 0 0 0 0

0 0 0 3642882 200000 1300000 1300000 0 8126137 789400 1041351 0 104387 126000 446159 80000 0 0 0 0

0 0

Annex 3 Funding, 20082012 (continued)

Contributions reported by donors Global Fund
3

WHO Region Contributions reported by countries DFID Government Global Fund The World Bank PMI/USAID Other bilaterals WHO UNICEF Other contributions5 PMI/USAID The World Bank

Country/area

Year

European Union

European
4 4 4 4

Tajikistan

Turkey

212 | WORLD MALARIA REPORT 2013

4 4 4 4

Uzbekistan

South-East Asia

Bangladesh

Bhutan

Democratic People's Republic of Korea

India

Indonesia

Myanmar

Nepal

Sri Lanka

Thailand

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

1 822 811 3 905 035 1 819 594 3 305 782 2 114 927 8 370 698 3 521 417 10 300 000 8 873 006 3 304 342 1 059 849 726 894 478 376 260 267 440 259 7 942 321 4 756 310 3 163 494 34 300 000 8 519 368 3 260 689 11 500 000 20 800 000 34 300 000 36 700 000 18 800 000 18 800 000 13 200 000 19 800 000 4 480 142 573 709 9 912 218 6 182 591 3 929 226 6 593 558 5 570 521 4 384 546 2 618 112 5 977 700 5 718 652 2 967 189 13 800 000 7 152 655

1 503 849 17 000 000

1 814 419

363439 393734 412825 416753 40865967 44200000 33486133 21821901 22927000 114772 126249 507457 1529810 1208161 528209 642129 1094385 8686483 4761717 191000 172826 211189 222222 213595 1000000 1200000 1800000 1875000 1882000 53360000 60222222 91551356 99525920 47240020 2135753 5594019 5787267 314000 375000 2250000 1259002 1000000 907770 907671 869401 192361 726465 2791905 1201268 1045455 1800000 572945 2827000 509557 439376 15252969 7098780

1464503 1332959 3353900 3403673 2068376 0 0 0 0 0 320045 450070 538393 583446 448627 9580687 7769852 5369344 8890744 7505444 579000 1163706 1315911 292324 0 8913265 2500899 6568434 13863557 9184373 13179273 6496121 7863868 13199217 17661982 31659696 40573846 11072851 5900000 10513382 924791 1305661 2765680 1907500 2960440 1432800 522431 1117464 5316488 1442758 3513961 5087163 3279977 3002074 16246556

0 700000 887995 439490 0 0 0 28619974 9480000 10265300 30898403 16696978 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 5500000 0 0 0 0 77541

0 0 0 0 0 0 0 0 0 0 0 0 0 0 173913 173913 188222 22600 146759 0 0 26311 0 2400000 2000000 2294000 1757475 0 0 0 0

75000 13000 13000 15000 20000 15000 0 0 0 0 7175 7892 0 0 0 220000 230000 135790 118000 98000 22000 17192 23622 22600 27898 1100000 1300000 42467 23000 5000 406000 103000 200000 222222 51141 300000 300000 300000 142500 88000 88000 46500 46500 46500 30000 24321 18000 7400 58118 73824 61408 104979

0 0 0 2800000 3300000 2027122 3111111 471362 4167142 1607882 1300000 948890 25000 0 0 0

0 0 0 0 0 0 0 1200000 1200000 0 0 0 0 0 2425633 3815436 870441 742500 0 3559305 2061759 566115 79772

WHO Region Contributions reported by donors Global Fund PMI/USAID The World Bank DFID3 Government Global Fund The World Bank PMI/USAID Other bilaterals WHO UNICEF Other contributions5 European Union Contributions reported by countries

Country/area

Year

South-East Asia

Timor-Leste

Western Pacic

Cambodia

China

Lao People's Democratic Republic

4 4

Malaysia

Papua New Guinea

4

4 4 4 4 4

Philippines

Republic of Korea

Solomon Islands

Vanuatu

Viet Nam

2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012

3 006 874 2 688 525 774 076 5 040 394 10 600 000 11 300 000 35 400 000 15 300 000 1 441 288 5 473 763 12 800 000 51 300 000 4 782 175 12 800 000 7 840 252 5 252 504 2 637 721 7 010 161 6 394 182 6 385 835 26 400 000 2 535 493 10 600 000 22 900 000 5 310 225 5 636 133 18 800 000 1 665 107 4 271 657

406 564 763 133 610 838

300816 46572 1858476 2278680 2687572 495155 1019923 1355728 3127120 3427795 594912 97690 470764 267890 23800000 23823040 24826273 37844710 44424578 64336 156 320580 190200 584290 1260000 3439132 3930233 3969519 3939519 792000 798000 788349 712000 681674 1075382 276195 1531001 840284 269486 846280 754651 812377 943619 812377 4599534 4582210 4476190 5229083 4615385

0 4698114 2367459 3902662 5375143 4327529 5534038 7157939 39422203 22685407 9133011 9901385 50874137 24430525 33697258 7242608 6424803 815252 4326267 4587596 0 0 0 0 6385835 4417383 1028735 23842245 3952832 31400000 21758417 12322318 7224199 3000000 4000000 0 0 0 483416 628188 1409315 1537685 1696290 264300 1581816 683607 2052359 2446418 2760895 4135547 8588884 5648842 3961323

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 1000000 1000000 0 0 456796 0 0 0 0 271773 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 80000 0 0 0 0 640741 0 0 0 0 620000 0 0 0 0 0 75000 75000 75000 75000 0 0 0 0 0 0 0 0 0 0 0 0 0

100000 145000 12500 41920 25000 590000 650000 1446616 380347 201718 0 21300 45925 46000 97000 0 0 0 0 2179 321338 200000 300000 300000 1222000 1096000 0 0 0 386000 216674 225000 697890 706000 267615 287615 287615 287615 287615 70000 70000 85000 108500 156804

0 0 239928 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 526500 0 0 0 0 0 60000 0 0 0 0 0 2500 0 3260803 8968127 466125 516000 769000 2501000 0 563681 750189 753085 6229231 5432362 1282500 1282500 1432500 2050753 1178215 0 0 0 0 0

0 0

WORLD MALARIA REPORT 2013 | 213

Source: The Global Fund website (malaria specic grants) Source: USAID internal database, The Presidents Malaria Initiative, Fifth Annual Report to Congress, April 2011; Sixth Annual Report to Congress, April 2012 Source: OECD Database 4 Budget not expenditure 5 Other contributions as reported by countries: NGOs, foundations, etc. 6 Where national totals for the United Republic of Tanzania are unavailable, refer to the sum of Mainland and Zanzibar. 7 South Sudan became a separate State on 10 July 2011 and a Member State of WHO on 27 September 2011. South Sudan and Sudan have distinct epidemiological proles comprising high-transmission and low-transmission areas respectively. For this reason data up to June 2011 from the high-transmission areas of Sudan (10 southern states which correspond to South Sudan) and low-transmission areas (15 northern states which correspond to contemporary Sudan) are reported separately * Negative disbursements reect recovery of funds on behalf of the nancing organization DFID, Department for International Development; PMI, Presidents Malaria Initiative; UNICEF, United Nations Childrens Fund; USAID, United States Agency for International Development

Annex 4  Intervention coverage estimated from routinely collected data, 20102012

WHO Region Country/area Year No. of ITN + LLIN sold or delivered No. of LLIN sold or delivered No. of ITN sold or delivered % of Modelled No. of people % IRS Any rst-line ACT treatment % any % ACT population % of protected coverage treatment courses antimalarial coverage2 1 potentially households by IRS courses delivered coverage protected 1 ITN delivered by ITNs (including delivered ACT) 38 39 34 19 100 100 22 18 21 100 99 87 99 100 100 10 71 71 74 38 39 5 58 56 74 69 68 22 71 21 86 75 46 62 90 18 1 2 26 45 35 59 60 71 0 48 93 100 15 39 93 5 2 3 40 26 34 37 73 79 75 100 74 67 62 76 42 41 100 38 65 86 20 35 44 45 45 51 30 33 35 54 55 50 64 76 81 14 15 18 26 63 75 44 48 44 39 56 59 24 26 28 24 27 27 55 68 68 52 56 59 30 47 65 59 58 78 81 86 87 38 27 31 51 47 53 50 49 50 10 10 11 63 55 63 63 63 67 45 45 49 63 81 77 56 51 49 77 70 87 0 0 13000 650782 689638 676090 636448 426232 694729 250961 207991 163647 113163 116708 115638 255474 224496 59300 175060 282265 282265 0 0 0 0 0 31922 0 0 0 98118 111972 103497 148092 177762 274143 89084 27029473 20865542 5721331 387274 747485 484086 849620 926699 2117240 35333 1487083 1832090 2435836 420532 834671 960000 9805575 10012822 5319060 2036430 321919 1873056 440815 697512 758021 0 0 0 3 3 3 7 4 7 20 16 13 1 1 1 4 3 1 100 100 100 0 0 0 0 0 5 0 0 0 0 0 0 20 3 5 1 46 35 9 23 43 27 4 4 8 0 5 6 7 11 20 23 47 46 24 14 2 12 3 5 5 408 191 887 3119744 3898070 3747190 1911338 27593 10149 4606 7989808 5918783 5720987 4258605 2343078 2183228 4835 6960 803231 1234405 762338 309927 122879 171090 117620 113705 202402 1721461 2349795 10315190 15240702 11693982 150199 27319 40199 285253 197403 219793 9205141 5058582 9000000 28883 427903 549830 484901 5600000 14493253 4170828 851811 924025 902516 18550714 12000000 6059525 6507544 422536 256452 2026100 7342770 7199048 6956822 294984 1719974 3842790 0 0 0 3119744 3898070 3747190 1911338 27593 10149 4606 7989808 5703335 5720987 3435597 1791325 2183228 3492 3960 803231 1234405 760375 447000 122879 171090 117620 113705 202402 1721461 2349795 10315190 15240702 11693982 49233 27319 40199 285253 197403 219793 9205141 5058582 9000000 19561 427903 549830 484901 5600000 14493253 4170828 851811 924025 802110 18550714 12000000 4581525 5064014 422536 256452 2026100 7202531 7202531 6956822 294984 1719974 3842790 100 100 100 74 100 99 63 100 100 100 100 100 100 100 100 100 100 70 15 29 21 9 4 100 74 8 14 34 56 61 89 68 67 13 22 100 100 100 100 100 100 8 88 100 93 88 100 60 20 21 21 100 100 100 100 64 31 100 100 100 100 9 50 100 74 100 99 63 100 100 100 100 100 100 100 100 100 100 40 15 29 21 12 4 100 71 8 14 34 56 61 89 68 22 13 22 100 100 100 100 64 100 2 88 100 93 88 100 60 20 21 18 100 100 100 100 64 31 100 100 100 100 9 50 100

African

Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali

2010 0 0 2011 0 2012 0 2010 1678365 1678365 2011 1720738 1720738 2012 477044 477044 2010 900000 900000 2011 5135942 5135942 2012 708643 708643 2010 84000 84000 2011 12000 12000 2012 52500 52500 2010 6892018 6892018 2011 774344 774344 2012 264432 264432 2010 1178843 1178843 2011 2869433 2869433 2012 703699 703699 2010 0 0 2011 0 2012 2010 187000 187000 2011 8115879 8115879 2012 217600 217600 2010 948274 948274 2011 0 2012 30000 30000 2010 353495 353495 2011 3495086 3495086 2012 2010 259558 259558 2011 9896 9896 2012 666 666 2010 0 0 2011 507763 507763 2012 1203982 1203982 2010 148804 148804 2011 8135784 8135784 2012 2010 2275207 2275207 2011 12033092 12033092 2012 18644449 18644449 2010 2011 2798 2798 2012 4431 4431 2010 102918 102918 2011 992779 992779 2012 83943 83943 2010 13798161 13798161 2011 4279165 4279165 2012 6260000 6260000 2010 0 2011 2012 2010 0 0 2011 734063 734063 2012 275042 275042 2010 1016900 1016900 2011 4151906 4151906 2012 7874094 7874094 2010 73862 73862 2011 48942 48942 2012 90188 90188 2010 68108 68108 2011 170442 170442 2012 73819 73819 2010 1176280 1176280 2011 9058461 9058461 2012 4226261 4226261 2010 883400 883400 2011 830000 830000 2012 2010 4986868 4986868 2011 510275 510275 2012 3939740 3939740 2010 1529665 1529665 2011 1017405 1037395 2012 6742108 6742108 2010 1020074 1020074 2011 4173156 4173156 2012 1935348 1935348

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

214 | WORLD MALARIA REPORT 2013

WHO Region

Country/area

Year

No. of ITN + LLIN sold or delivered

No. of LLIN sold or delivered

No. of ITN sold or delivered

African

Mauritania Mayotte, France Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania Mainland Zanzibar Zambia Zimbabwe

Region of the Americas

Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador

2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012

872268 139690 13000 1525979 3244164 2669244 87900 87900 93900 783772 516550 541550 18866196 18141631 14448634 4763739 816915 1675233 47403 4985 105312 621481 2465770 267482 3413311 45833 139391 71336 47857 40612 247263 2547606 329999 7400000 709000 1000747 8614613 14481950 2208293 8584760 14452674 1535867 29853 29276 672426 1058050 3532137 2688575 1219309 0 457000 0 0 42950 42800 24526 94611 13739 361241 73500 274682 313398 6000 4000 3000 83918 70437 62095 68860 30022 13502

872268 139690 13000 2197 2543 40988 1525979 3244164 2669244 87900 87900 93900 783772 516550 541550 18139218 18141631 14448634 4763739 816915 1675233 47403 4985 105312 621481 2465770 267482 3413311 45833 139391 71336 47857 40612 247263 2537528 329999 7400000 709000 1000747 8614613 14481950 2208293 8584760 14452674 1535867 29853 29276 672426 1058050 3532137 2688575 1219309 0 457000 0 0 0 42950 42800 24526 94611 13739 361241 70000 262732 313398 6000 4000 3000 83918 70437 62095 68860 30022 13502

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3500 11950 0 0 0 0 0 0 0

% of Modelled No. of people % IRS Any rst-line ACT treatment % any % ACT population % of protected coverage treatment courses antimalarial coverage2 1 potentially households by IRS courses delivered coverage protected 1 ITN delivered by ITNs (including delivered ACT) 51 11 126162 126162 20 20 55 12 64078 64078 10 10 54 13 9 40560 90 18 23559 51 100 4339 9 37 32 7513172 31 7671350 7671350 96 96 44 46 8532525 35 9391810 9391810 100 100 53 57 1789110 7 5106570 5106570 72 72 56 80 566419 36 87520 87520 100 100 30 76 599939 38 110031 110031 100 100 30 70 559305 34 22313 22313 100 100 13 74 0 0 2225253 2225253 52 52 14 76 186603 1 3199290 3199290 73 73 19 70 192761 1 3500243 3500243 74 74 50 37 200000 0 9980728 9980728 20 20 61 43 177235 0 7648896 7648896 16 16 54 43 2415540 1 12877360 12877360 27 27 79 75 1646781 15 802223 788513 100 100 90 87 1571625 14 288508 284788 48 48 100 78 1080889 9 619786 611482 95 93 87 47 65442 37 6111 6111 100 100 80 50 115610 63 11546 11546 100 100 100 52 146773 78 10703 10703 100 100 62 70 951620 7 835954 835954 26 26 72 66 887315 7 675707 675707 19 19 44 78 1095093 8 713344 713344 19 19 100 52 308209 5 2161564 2161564 100 100 15 1873610 1873610 100 100 100 86 851000 100 98 986898 17 2004308 2004308 100 100 28 5000000 97 32 5000000 96 7620 7620 77 81 37 5000000 95 3897 3897 57 57 49 47 3320 3320 100 100 63 61 1750 1750 100 100 83 69 350 350 47 47 55 66 0 0 77 56 0 0 659800 39 84 65 0 0 812911 914218 52 58 56 50 2732418 8 46 60 2543983 7 19579200 19579200 100 100 45 64 2543983 7 23864320 23864320 100 100 34 65 7530944 16651795 16651795 100 100 30 80 7628362 16775381 16775381 100 100 92 6596263 10175160 10175160 100 100 69 65 6500000 15 16606080 16606080 100 100 100 80 6534333 15 16727880 16727880 100 100 95 92 6340333 14 10128060 10128060 100 100 70 1030944 76 45715 45715 100 100 45 1094029 78 47501 47501 100 100 93 255930 18 47100 47100 100 100 52 60 5951303 45 6147359 6147359 100 100 81 46 7542497 56 6957420 6957420 100 100 94 65 4250000 31 4289743 4289743 100 100 55 51 3090289 49 1213001 1213001 100 100 52 60 3299058 52 2079657 2079657 100 100 46 64 3106659 48 1236958 1236958 100 100 12008 6 100 100 100 23068 11 100 100 100 26712 13 50 100 100 0 100 2 50121 24 150 2 31363 14 79 1 100 100 20052 9 37 1 100 100 20 35365 7 13796 1200 97 100 33 45214 9 7200 923 100 100 39 28000 6 7400 350 100 99 6 508667 11 515015 78965 100 100 6 714128 16 445531 114081 100 100 18 369103 8 905010 141410 100 100 6 260000 4 209473 42688 100 100 11 1032000 15 92518 27698 100 100 16 359100 5 171342 50398 100 100 32 16400 35 1140 0 100 100 47 48000 100 170 0 100 100 49 22000 46 50 0 100 38 53057 12 2479 3 100 64 78236 18 1608 8 100 88 61557 14 947 5 99 100 163572 73 1753 500 93 100 100 105234 46 87 83357 36

WORLD MALARIA REPORT 2013 | 215

Annex 4  Intervention coverage estimated from routinely collected data, 20102012 (continued)
WHO Region Country/area Year No. of ITN + LLIN sold or delivered No. of LLIN sold or delivered No. of ITN sold or delivered % of Modelled No. of people % IRS Any rst-line ACT treatment % any % ACT population % of protected coverage treatment courses antimalarial coverage2 1 potentially households by IRS courses delivered coverage protected 1 ITN delivered by ITNs (including delivered ACT) 30772 2 115256 0 100 100 26167 2 109635 0 100 16905 1 124753 0 100 100 6 40784 21 6 148855 7 0 0 1 42555 2 6822 0 100 50 65390 3 7966 0 100 11 0 0 22935 14383 100 99 18 19320 7 29471 20299 87 87 28 20700 7 31601 20291 87 87 4 0 0 168985 0 100 0 0 113958 0 100 100 0 0 117293 0 100 1 65187 6 93845 1 100 3 83858 8 74533 1 100 7 75777 7 36431 1 100 100 106875 30 3 100 100 69331 19 3 100 100 42985 12 2 100 100 262373 100 59600 1 100 100 200448 100 206511 1 100 100 87446 100 218419 1 100 82041 51 836 0 100 23766 14 420 0 100 21071 13 920 0 100 1 36035 15 27 0 100 100 34736 15 10 0 100 100 40126 17 15 0 100 100 63 33 32 6 5244247 100 45155 10629 95 81 4 3589089 100 3 3637795 100 51 100 0 0 98 0 0 96 57 37 64 23 78 0 10 222470 5 11358 7245 100 100 10 84484 2 5976 3417 100 100 17 512991 11 5670 3100 100 100 2 1 2 4584426 9 2280000 596600 65 4 30 2500000 71 3000 1600 100 100 21 2600000 72 2724 2724 100 100 46 2210000 60 1283 1283 100 100 20 18 16261 0 95000 95000 26 26 21 19 429514 7 20 20 240558 3 18868 9268 3 1 100 50 100 44 60 46 170440 2 4333150 4333150 100 100 2339473 2285901 61 57 39 58 2480360 8 33 53 2947155 10 2546884 2512852 64 60 22 38 3967730 13 2478038 2462470 65 62 17 1099627 11 183177 177517 60 59 11 1480416 15 273180 273180 100 100 31 1886500 18 179000 166500 70 66 26 1250000 100 54 2 100 100 34 309162 100 10 2 100 100 18 211500 99 4 1 100 100 100 335000 100 6 0 100 100 100 223000 100 5 0 100 100 100 146466 100 3 0 100 100 69 814500 100 112 1 100 100 100 644136 100 78 5 100 100 100 503156 100 31 2 100 100 390460 100 250 100 100 100 221225 100 205 105 100 100 50 0 600 235 100 100 65 244821 100 5 0 100 100 100 300543 100 1 0 100 100 100 375605 100 1 1 100 100

Region of the Americas

El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of )

Eastern Mediterranean

Afghanistan Djibouti Iran (Islamic Republic of ) Pakistan Saudi Arabia Somalia

South Sudan3

Sudan Yemen European Azerbaijan Kyrgyzstan Tajikistan Turkey Uzbekistan

2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012

2565 8077 0 618803 11430 14550 16800 0 0 2987653 6378 8798 30630 350000 0 52766 22800 14300 18350 0 0 0 0 0 14073 712 9267 1665 515 922956 3352326 37551 28300 100 26400 120000 60000 243728 439181 81050 100000 767000 131467 210231 455000 2203040 386563 1036109 1166240 882901 1643518 538577 21831 1209215 10000 10000 1000 70000 48600 35000 38778 117041 100000 0 0 50000 20000

0 0 0 8077 0 618803 11430 14550 16800 0 0 2987653 6378 8798 30630 350000 0 52766 22800 14300 18350 0 0 0 0 0 0 14073 712 9267 1665 515 922956 3352326 37551 28300 100 26400 120000 60000 243728 439181 81050 100000 767000 131467 210231 455000 2203040 386563 1036109 1166240 882901 1643518 538577 21831 1209215 10000 10000 1000 70000 48600 35000 38778 117041 100000 0 0 0 0 50000 20000

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

216 | WORLD MALARIA REPORT 2013

WHO Region

Country/area

Year

No. of ITN + LLIN sold or delivered

No. of LLIN sold or delivered

No. of ITN sold or delivered

South-East Asia

Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste

Western Pacic

Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam

2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012

1696943 2890013 85976 100671 8942 10000 300000 79960 332000 2570000 6580000 0 2402610 2829748 845712 778264 1613830 2964812 438186 934476 499166 166600 1274000 637250 597497 232150 251117 166605 24613 25148 239603 1212490 2177808 692126 656674 257935 231192 241935 30396 221911 260487 220703 878831 1268939 1080806 1437327 98625 783463 10000 10000 314478 46574 31781 91281 92385 35863 1181438 766606 968413

500000 1391953 20052 99697 8942 10000 300000 79960 332000 2570000 6580000 0 2402610 2829748 845712 329421 551107 1042244 438186 934476 499166 166600 636750 637250 201566 100343 139000 166605 24613 25148 217351 1203321 2177808 114529 149394 0 230292 241935 30396 221911 260487 220703 878831 1268939 1080806 1437327 3037404 783463 10000 10000 0 314478 46574 31781 91281 92385 35863 500000 100000 0

1196943 1498060 65924 974 0 0 0 0 0 0 0 448843 1062723 1922568 0 0 0 395931 131807 125806 0 0 22252 9169 0 577597 507280 257935 900 0 0 0 0 0 0 0 0 0 0 0 681438 666606 968413

% of Modelled population % of potentially households protected 1 ITN by ITNs delivered 100 100 89 100 100 100 21 26 43 3 8 6 23 28 26 10 20 35 100 100 100 45 59 53 44 32 23 53 41 45 36 69 100 100 100 100 100 42 84 100 100 100 46 68 86 87 100 100 1 1 1 100 100 100 100 100 100 14 14 18

No. of people % IRS Any rst-line ACT treatment % any % ACT protected coverage treatment courses antimalarial coverage2 1 by IRS courses delivered coverage delivered (including ACT) 0 0 68802 58135 75 78 0 0 68540 48540 100 100 0 0 94810 71040 100 100 140503 100 780 266 100 100 148318 100 125 125 53 100 141322 100 82 35 100 100 2000000 68 15392 0 100 100 2013084 68 18104 0 100 100 1646580 55 23537 0 100 100 53432930 20 1599986 2875000 100 100 53348697 20 330000000 2920000 100 100 49942758 18 30523925 3147400 100 100 60000 0 671681 671681 27 52 527535 1 479850 479850 16 29 110000 0 341697 341697 13 24 12709 0 266769 266769 31 43 1036 0 594756 569607 96 100 56414 0 546060 546060 78 100 768350 77 150000 3200 100 13 256070 25 71140 612 91 6 443229 44 669152 53252 100 100 314146 7 736 34 100 100 80499 2 175 17 100 100 75354 2 70 48 100 100 568799 11 51161 26471 100 100 423638 8 5642 5642 100 100 451730 8 3298 3298 100 100 58425 7 40250 28718 33 33 102858 12 19739 15981 54 54 159743 19 5211 2923 100 100 0 0 198390 182046 100 100 0 0 206529 120529 100 100 0 0 422024 422024 100 100 24561489 100 1043963 100 1096877 100 0 0 51425 51425 100 100 0 0 56340 56340 100 100 1856 0 80412 80412 100 100 365340 43 6650 100 307769 36 5306 2218 100 100 489988 56 4725 2088 100 100 1063275 16 36298 36298 100 100 1052050 15 34080 34080 100 100 1541860 22 13469 13469 100 100 1772 67 838 70 555 71 166053 32 271946 271946 100 100 175265 33 236665 236665 100 100 131752 24 190255 190255 100 100 16204 7 49600 49600 100 100 18490 8 9705 4 52010 52010 99 100 1602475 10 346887 100 1555892 10 274852 110576 100 100 1364815 9 266351 100

1 2 3

Based on Probable and conrmed cases adjusting for reporting completeness and any rst-line treatment courses distributed as proxy indicator for treated cases Based on Probable and conrmed cases adjusting for reporting completeness and % of P. falciparum using ACT distributed as proxy indicator for treated cases  South Sudan became a separate State on 9 July 2011 and a Member State of WHO on 27 September 2011. South Sudan and Sudan have distinct epidemiological proles comprising high-transmission and low-transmission areas respectively. For this reason data up to June 2011 from the high-transmission areas of Sudan (10 southern states which correspond to South Sudan) and low-transmission areas (15 northern states which correspond to contemporary Sudan) are reported separately.

WORLD MALARIA REPORT 2013 | 217

Annex 5 Household Surveys, 20082012

WHO Region Country/area Year Source Subgroup % of HH that have at least ITN % of HH with enough ITNs for individuals who slept in the house the previous nigh 6 7 5 17 24 15 22 28 21 23 4 9 30 14 16 14 18 27 38 23 10 9 11 16 18 13 17 25 15 31 43 29 19 29 17 18 31 37 29 22 2 2 2 14 11 15 15 24 13 39 50 37 31 38 25 11 10 12 15 12 18 6 6 5 % of population with access to an ITN in their household % of existing ITNs in HH used the previous night % of the population who slept under an ITN the previous night 19 19 18 31 31 31 37 50 35 47 7 25 32 26 20 14 25 35 46 32 22 19 24 31 33 29 36 42 34 66 70 66 28 37 27 40 55 54 55 29 3 3 3 23 16 25 39 45 38 57 62 56 46 56 34 22 22 23 28 25 31 19 17 19

African

Angola

Burkina Faso

Burundi

Cameroon Congo Cte d'Ivoire Democratic Republic of the Congo

Ethiopia

Gabon Ghana

Kenya

Lesotho

Liberia

Madagascar

Malawi

Mali

Mozambique

Nigeria

Rwanda

Sao Tome and Principe

Senegal

Sierra Leone

2011 2011 2011 2010 2010 2010 2010 2010 2010 2012 2011 2012 2012 2010 2010 2010 2011 2011 2011 2012 2008 2008 2008 2009 2009 2009 2009 2009 2009 2009 2009 2009 2011 2011 2011 2009 2009 2009 2011 2011 2011 2010 2010 2010 2012 2010 2010 2010 2008 2008 2008 2011 2008 2008 2008 2010 2010 2010 2008 2008 2008 2010 2010 2010 2009 2009 2009 2009 2009 2009 2011 2011 2011 2008 2008 2008

MIS 2011 MIS 2011 MIS 2011 DHS 2010 DHS 2010 DHS 2010 DHS 2010 DHS 2010 DHS 2010 MIS 2012 DHS 2011 DHS 2012 DHS 2012 MICS 2010 MICS 2010 MICS 2010 DHS 2011 DHS 2011 DHS 2011 DHS 2012 DHS 2008 DHS 2008 DHS 2008 DHS 2009 DHS 2009 DHS 2009 DHS 2009 DHS 2009 DHS 2009 MIS 2009 MIS 2009 MIS 2009 MIS 2011 MIS 2011 MIS 2011 DHS 2009 DHS 2009 DHS 2009 MIS 2011 MIS 2011 MIS 2011 DHS 2010 DHS 2010 DHS 2010 MIS 2012 DHS 2010 DHS 2010 DHS 2010 MICS 2008 MICS 2008 MICS 2008 DHS 2011 DHS 2008 DHS 2008 DHS 2008 MIS 2010 MIS 2010 MIS 2010 DHS 2008 DHS 2008 DHS 2008 DHS 2010 DHS 2010 DHS 2010 DHS 2009 DHS 2009 DHS 2009 MIS 2009 MIS 2009 MIS 2009 DHS 2011 DHS 2011 DHS 2011 DHS 2008 DHS 2008 DHS 2008

Total Urban Rural Total Urban Rural Total Urban Rural Total Total Total Total Total Urban Rural Total Urban Rural Total Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Total Urban Rural Total Urban Rural Total Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural

35 39 32 57 60 56 52 68 50 63 18 33 67 98 99 98 36 42 35 48 56 58 55 47 42 52 50 52 47 57 60 56 81 87 80 57 64 55 55 86 87 86 51 8 9 8 42 33 45 56 65 54 82 84 82 61 69 52 60 50 70 63 52 73 37 36 37

19 22 17 36 40 35 39 51 38 46 11 23 49 27 30 26 34 42 52 40 25 22 28 31 34 28 35 43 33 57 67 56 38 47 36 37 62 62 61 37 5 5 5 28 23 30 38 49 36 64 71 63 51 58 43 35 29 39 38 30 45 19 19 19

84 81 86 82 76 84 74 85 72 83 62 90 62 87 63 54 69 77 80 76 76 79 75 83 82 84 83 86 82 88 89 88 65 72 63 91 88 87 88 70 68 64 70 77 66 80 84 84 84 71 74 71 82 90 71 64 71 60 69 74 66 89 84 92

218 | WORLD MALARIA REPORT 2013

% of the children <5 years who slept under an ITN the previous night 26 29 24 47 45 47 44 62 43 53 11 31 37 39 38 32 42 46 61 43 26 23 27 36 39 34 45 55 44 75 79 75 39 47 37 56 70 66 71 35 5 7 5 29 22 31 56 61 55 69 74 68 56 66 46 29 29 29 34 31 36 25 29 24

% of pregnant women who slept under an ITN the previous night

% of HH sprayed by IRS within last 12 months

% of HH with = 1 ITN for 2 pers. and/or sprayed by IRS within last 12 months 18 25 16 22 29 22 27 11 31 20 26 25 27 62 51 64 25 37 15 12 16 24 20 28

% of children aged 6-59 months with a hemoglobin measurement <8g/dL 3 2 3 26 15 28 3 2 3 6 4 12 5 5 6 5 19 13 23 4 7 3 5 6 5 8 8 8 3 3 2 1 2 1 9 7 9 9 10 2 2 2 1 2 1 3 2 3 17 13 20 14 10 16 10 8 11

% of children % children <5 aged 6-59 months years with fever with a positive in last 2 weeks microscopy blood for whom advice smear or treatment was sought 10 1 14 66 30 73 17 17 33 23 40 28 17 35 7 1 7 28 38 5 45 35 42 23 48 1 0 1 3 2 4 59 71 54 66 74 64 66 72 66 59 59 67 67 44 39 46 27 42 25 71 71 82 64 64 63 64 66 60 67 80 82 78 77 81 74 49 65 47 44 56 43 74 73 74 59 68 73 66 63 72 77 70 84 86 84 46 50 46 52 66 50 74 65 82 52 61 46 54 62 45 57 72 52

% of children <5 years with fever in last 2 weeks who received an ACT among those who received any antimalarial 77 81 72 25 31 23 69 44 70 71 26 40 18 37 37 50 59 43 33 51 28 45 36 52 70 60 76 6 14 5 0 27 19 82 80 82 91 60 7 10 6 12 21 9 90 84 91 95 92 95 34 23 60 50 43 57 41 48 32 23 16 27

% of children <5 years with fever in the last 2 weeks who had a nger or heel stick 5 8 5 27 48 26 48 29 11 18 33 13 15 33 38 30 6 9 6 36 30 6 5 6 21 40 18 10 10 9

% of women who received at least 2 doses of IPT during ANC visits during their last pregnancy 19 33 12 39 41 39 0 0 0 26 28 25 47 51 44 17 20 17 48 51 47 51 44 56 7 7 7 20 29 20 55 56 55 53 67 47 7 10 5 15 22 13 18 22 17 65 70 59 57 55 57 40 46 37 13 16 12

26 28 24 44 38 46 49 64 48 55 10 26 40 28 27 17 34 48 51 47 32 28 34 39 38 39 46 50 45 70 73 70 35 43 34 51 34 5 5 5 34 16 39 60 63 60 72 78 70 56 69 42 29 26 31 36 32 38 27 22 30

1 2 1 0 2 0 6 3 2 6 12 8 16 41 12 44 9 19 1 1 1 11 9 12

WORLD MALARIA REPORT 2013 | 219

Annex 5 Household Surveys, 20082012 (continued)

WHO Region Country/area Year Source Subgroup % of HH that have at least ITN % of HH with enough ITNs for individuals who slept in the house the previous nigh 15 22 14 26 37 24 13 27 8 20 28 17 52 13 27 8 20 28 17 52 59 50 12 9 13 18 9 22 5 10 14 9 % of population with access to an ITN in their household % of existing ITNs in HH used the previous night % of the population who slept under an ITN the previous night 25 30 24 34 41 33 20 41 14 43 47 42 65 20 41 14 43 47 42 65 69 65 8 7 9 21 10 25 7 29 37 26

African

Swaziland

Uganda

United Republic of Tanzania

United Republic of Tanzania (Mainland)

Zimbabwe

Region of the Americas

Bolivia (Plurinational State of )

Colombia

Guyana

Haiti Honduras Peru

Eastern Mediterranean

Egypt

Jordan

European

Albania

South-East Asia

Bangladesh Indonesia Maldives

Nepal

Timor-Leste

Western Pacic

Cambodia

Philippines

2010 2010 2010 2009 2009 2009 2011 2011 2011 2008 2008 2008 2010 2010 2010 2012 2008 2008 2008 2010 2010 2010 2012 2012 2012 2009 2009 2009 2011 2011 2011 2008 2008 2008 2010 2010 2010 2009 2009 2009 2012 2012 2008 2008 2008 2008 2008 2008 2009 2009 2009 2009 2009 2009 2011 2012 2009 2009 2009 2011 2011 2011 2010 2010 2010 2010 2010 2010 2008 2008 2008

MICS 2010 MICS 2010 MICS 2010 MIS 2009 MIS 2009 MIS 2009 DHS 2011 DHS 2011 DHS 2011 DHS 2008 DHS 2008 DHS 2008 DHS 2010 DHS 2010 DHS 2010 DHS 2012 DHS 2008 DHS 2008 DHS 2008 DHS 2010 DHS 2010 DHS 2010 DHS 2012 DHS 2012 DHS 2012 MICS 2009 MICS 2009 MICS 2009 DHS 2011 DHS 2011 DHS 2011 DHS 2008 DHS 2008 DHS 2008 DHS 2010 DHS 2010 DHS 2010 DHS 2009 DHS 2009 DHS 2009 DHS 2012 DHS 2012 DHS 2008 DHS 2008 DHS 2008 DHS 2008 DHS 2008 DHS 2008 DHS 2009 DHS 2009 DHS 2009 DHS 2009 DHS 2009 DHS 2009 DHS 2011 DHS 2012 DHS 2009 DHS 2009 DHS 2009 DHS 2011 DHS 2011 DHS 2011 DHS 2010 DHS 2010 DHS 2010 DHS 2010 DHS 2010 DHS 2010 DHS 2008 DHS 2008 DHS 2008

Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Total Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Total Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural

99 95 100 47 46 47 60 59 60 39 59 33 64 65 63 91 39 59 33 64 65 63 91 87 92 87 78 91 29 23 32 26 13 31 19 41 51 38

32 37 31 45 52 44 25 45 20 47 51 45 74 25 45 20 47 51 45 74 77 74 20 16 22 22 11 27 11 26 33 23

79 85 78 75 81 74 70 84 61 82 87 80 77 70 84 61 82 87 80 77 80 76 39 45 37 88 87 89 64 92 94 91

DHS = Demographic and Health Survey MICS = Multiple Indicator Cluster Survey MIS = Malaria Indicator Survey HH = Households IPTp = intermittent preventive treatment in pregnancy IRS = indoor residual spraying TN = insecticide-treated mosquito net

220 | WORLD MALARIA REPORT 2013

% of the children <5 years who slept under an ITN the previous night 32 32 32 42 48 41 25 47 20 62 61 62 70 25 47 20 62 61 62 70 71 70 91 85 94 10 10 9 24 12 28 12 41 50 38

% of pregnant women who slept under an ITN the previous night

% of HH sprayed by IRS within last 12 months

% of HH with = 1 ITN for 2 pers. and/or sprayed by IRS within last 12 months 32 41 30 67 82 62 61 67 82 62 61 65 60 26 13 32 7

% of children aged 6-59 months with a hemoglobin measurement <8g/dL 10 3 11 5 2 5 8 9 7 6 6 6 6 8 9 7 6 6 6 6 6 6 4 4 4 7 7 7 2 2 2 4 1 2 2 3 1 1 2 1 0 1 2 2 2 2 1 1 1 3 1 3

% of children % children <5 aged 6-59 months years with fever with a positive in last 2 weeks microscopy blood for whom advice smear or treatment was sought 43 17 46 4 4 1 5 55 56 54 83 69 85 85 93 84 75 87 72 85 89 84 79 75 87 72 85 89 84 79 83 78 52 46 53 44 44 44 56 65 47 60 62 55 67 67 67 49 64 74 77 72 72 73 71 78 79 78 75 90 86 87 85 72 81 70 73 78 71 83 87 82 49 53 46

% of children <5 years with fever in last 2 weeks who received an ACT among those who received any antimalarial 24 24 39 50 37 68 70 68 38 39 37 62 50 67 61 38 39 37 62 50 67 61 45 65 43 38 45 2 27 6 1 9 7 7

% of children <5 years with fever in the last 2 weeks who had a nger or heel stick 14 14 14 26 53 23 25 25 61 17 7 5 8 12

% of women who received at least 2 doses of IPT during ANC visits during their last pregnancy 1 1 2 34 46 33 27 31 27 31 44 29 28 32 27 15 8 18 8 6 8 0 0

44 45 43 46 55 45 27 47 22 56 46 59 74 27 47 22 56 46 59 74 74 74 27 35 24 10 8 10 30 13 35 8 41 49 38

8 6 8 61 76 56 15 61 76 56 15 13 15 19 5 26 2

WORLD MALARIA REPORT 2013 | 221

Annex 6A R  eported malaria cases and deaths, 2012

WHO Region Country/area UN population African Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali Mauritania Mayotte Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania Mainland Zanzibar Zambia Zimbabwe Argentina Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of ) Afghanistan Djibouti Iran (Islamic Republic of ) Iraq Pakistan 38481705 20820525 10050702 2003910 16460141 9849569 494401 21699631 4525209 12448175 717503 4337051 19839750 65705093 736296 6130922 91728849 1632572 1791225 25366462 11451273 1663558 43178141 4190435 22293914 15906483 14853572 3796141 216230 25203395 2259393 17157042 168833776 11457801 188098 13726021 5978727 52385920 1230985 6642928 36345860 47783107 46444390 1409845 13883577 13013678 41086927 324060 10496285 198656019 47704427 4805295 10276621 15492264 6297394 243076 15082831 795369 10173775 7935846 120847477 5991733 3802281 6687361 29987800 534541 29954782 29824536 859652 76424443 32778030 179160111 Population At risk (low + high) N/A 20820525 10050702 1302542 16460141 7682664 N/A 21699631 4525209 12323693 717503 4337051 19839750 65705093 736296 6130922 61458329 1632572 1791225 25366462 11451273 1663558 32815387 4190435 22293914 15906483 14853572 3416527 N/A 25203395 1626763 17157042 168833776 11457801 188098 13726021 5978727 5238592 344676 6642928 36345860 47783107 46444390 1409845 13883577 6506839 N/A 223601 3705189 40327172 10733496 N/A 8796788 N/A N/A 243076 6862688 739693 10173775 5777296 N/A 3007850 2874524 N/A 4798048 83923 5631499 23099103 429826 N/A N/A 176132305 At risk (high) N/A 20820525 10050702 360704 16460141 2363897 N/A 15406738 4525209 9958540 674453 4337051 19839750 63733940 736296 4352955 917288 1632572 1791225 25366462 11451273 1663558 15544131 4190435 6688174 15906483 13368215 2239723 N/A 25203395 1513793 11838359 168833776 11457801 188098 13176980 5978727 2095437 0 6642928 32711274 34881668 33904405 1409845 13883577 6506839 N/A 0 503822 4569088 7060255 N/A 441895 N/A N/A 207830 2262425 278379 5392101 1111018 N/A 77893 167300 N/A 1349451 83923 778824 7960169 0 N/A N/A 51813104 Number of people living in active foci 22799649 N/A N/A N/A N/A N/A 283206 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 3477 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A 2500 N/A 231908 7958 N/A N/A N/A N/A N/A 4159043 N/A N/A 497042 N/A N/A N/A N/A N/A 764315 0 Reported malaria cases Suspected malaria Presumed cases and conrmed malaria cases 15790 3314706 1513212 308 6970700 3808337 17430 1589317 459999 660575 152744 117640 2795919 9128398 40071 138982 5962647 188089 862442 10676731 1220574 158095 9335951 2048883 944533 5265474 2171739 169104 1463 4781207 10844 3888044 6938519 3095386 126897 637594 2170759 152561 1401 1240134 13591932 8477435 8474278 536524 4695400 727174 7027 20789 132904 2349341 416767 7485 506583 459157 124885 13638 186645 196622 161236 141165 1025659 552722 107711 31499 759285 17464 410663 847933 1410 8902947 887 1496834 1151038 308 6089101 2151076 8751 313315 451012 590786 49840 117640 2168215 6263607 15169 42178 3876745 137695 271038 8774516 1220574 50381 5788381 1407455 359420 3659565 2171739 165834 72 1813984 3163 3525112 2087068 483470 12550 366912 1537322 6846 626 697374 10338093 2441750 2972186 2931 4695400 276963 4 37 7415 242758 60179 8 952 558 19 900 5346 31601 25423 6434 833 1235 844 15 31436 569 52803 391365 25 1629 8 4285449

Region of the Americas

Region of the Americas Eastern Mediterranean

222 | WORLD MALARIA REPORT 2013

Reported malaria cases Malaria case denition P+C S S P+C S S P+C S S S S S S S S P+C P+C S S S S S S S S S S S #N/A S P+C S S P+C P+C S S P+C P+C S S S S S S P+C C C C C C C C C C C C C C C C C C C C C C P+C P+C C C P+C Mic. slides/ RDTs performed 15790 3314706 1068013 81 4739645 3808337 8715 1276002 55746 69789 152744 0 1768331 7656389 40071 118619 3778480 70147 862442 5657381 158095 5001041 2048883 944533 3170893 0 5158 1463 4781207 7875 1205275 4851451 3095386 126897 552640 2170759 151344 1070 1240134 5916097 8022640 7486116 536524 727174 7027 20789 132904 2349341 416767 7485 506583 459157 124885 13638 186645 196622 161236 141165 1025659 552722 107711 31499 759285 20810 410663 511408 1410 479655 1963638 4908279 Mic. slides/ RDTs positive 887 1496834 705839 193 3858046 2151076 36 46759 49840 0 1140627 4791598 15169 21815 1692578 19753 300363 3755166 317200 50381 1453471 1407455 359420 1564984 886482 1888 72 1813984 194 842343 483470 12550 281958 1537322 5629 295 697374 2662258 1986955 1984024 2931 276963 4 37 7415 242758 60179 8 952 558 19 900 5346 31601 25423 6444 833 1235 844 15 31570 345 52803 54840 25 1629 8 290781 Mic. slides/ RDTs P. falciparum 860 193 36 43681 15169 12121 946595 271038 3755166 191421 1453471 1407455 66 927841 194 817073 483470 10700 281958 1537322 3109 78 260526 1413149 2730 2730 1 396 35903 17612 950 80 3 386 68 20320 25423 582 236 1 11 3399 126 13302 1231 25 144 95095 Mic. slides/ RDTs P. vivax 24 0 637 9204 745983 0 2 0 0 1 5 0 0 0 0 0 36 7067 203018 44283 2 478 16 257 5278 11225 0 5862 999 843 4 28164 167 39478 53609 0 1418 228215 Imported cases / (Introduced cases) 828 /(3) 35 47 4 1 349 14 6 1 48 2 9 0 8 15 1539 842 /(12) 8 Cases at community level 556516 344280 29532 139406 40807 0 140781 39853 13106 77589 41377 5174 61646 114639 92994 0 1806424 80382 0 17198 1315465 0 211755 0 0 0 5272 31546 0 0 0 134 248 177827 0 0

Inpatient malaria cases and deaths Inpatient malaria cases 152666 78769 68 393195 113820 36 364451 73083 16841 15930 47822 157332 851094 5440 4802 54021 11001 9830 438284 27814 15002 22854 62936 9380 31209 18130 23 78657 50 233283 843187 5306 2354 11905 81053 645 109 30068 592264 300884 300690 194 161385 7820 0 0 0 3328 324 0 6 110 525 713 0 236 36 1 71 10 4220 0 73 0 57188 Malaria attributed deaths 0 5736 2261 3 7963 2263 0 3209 1442 1359 17 623 1534 21601 77 30 1621 134 289 2855 979 370 785 1725 552 5516 1894 106 0 2818 4 2825 7734 459 7 649 3611 72 7 1197 6585 7820 7812 8 3705 351 0 0 0 64 20 0 8 0 0 2 0 3 0 1 0 2 0 0 2 0 6 36 0 0 260

WORLD MALARIA REPORT 2013 | 223

Annex 6A R  eported malaria cases and deaths, 2012 (continued)

WHO Region Country/area UN population Saudi Arabia Somalia South Sudan2 Sudan3 Yemen Azerbaijan Georgia Kyrgyzstan Tajikistan Turkey Uzbekistan Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam 28287855 10195134 10837527 37195349 23852409 9308959 4358242 5474213 8008990 73997128 28541423 154695368 741822 24763188 1236686732 246864191 52797319 27474377 21098099 66785001 1114106 14864646 1377064907 6645827 29239927 7167010 96706764 49002683 549598 247262 90795769 Population At risk (low + high) N/A 10195134 10837527 37195349 15675803 N/A N/A N/A N/A N/A N/A 16026440 N/A N/A 1100651191 150587157 31678391 22968579 N/A 33392501 1114106 7878262 575911328 3921038 N/A 7167010 77155915 N/A 544102 244789 34042276 At risk (high) N/A 7136594 10837527 30872140 10330478 N/A N/A N/A N/A N/A N/A 4114897 N/A N/A 272071081 41966912 19535008 1016552 N/A 5342800 857862 6540444 196109 2392498 N/A 6736989 6937659 N/A 544102 244789 15939973 Number of people living in active foci 2299447 N/A N/A N/A N/A 11780 5000 22900 2153560 2500 0 N/A 518453 18695170 N/A N/A N/A N/A 500974 N/A N/A N/A N/A N/A 1187920 N/A N/A 3758499 N/A N/A N/A Reported malaria cases Suspected malaria Presumed cases and conrmed malaria cases 2348433 891394 497040 1046 18268 209239 337830 805761 309179 42512 39238 122159270 3534331 1423966 243432 948250 1130757 182854 194263 6918770 369976 1566872 878371 332063 555 249520 66546 3436534 3406 59709 1125039 964698 165678 4 5 3 33 376 1 29518 82 21850 1067824 2051425 480586 70272 93 32569 6148 45553 2718 46819 4725 643214 7133 555 57296 36708 43717

European

South-East Asia

Western Pacic

UN Population African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic Total 886954443 550235060 435517419 124999941 1860447520 1582602730 5525288566

At risk (low + high) 755090196 104853958 263520743 1355304259 673936551 3152705707

At risk (high) 605389229 30012219 109398358 344047250 24450453 1113297508

Number of people living in active foci 23086332 4898451 3063762 2195740 19714597 4946419 57905301

Suspected malaria cases 114956836 7945758 12511386 1954817 130636696 10759790 287316314

Presumed and conrmed malaria cases 69439866 693529 6884131 166099 3754220 850869 89728774

Mala case de

C=conrmed P=presumed S=suspected N/A=not applicable RDT, rapid diagnostic test 1  Method 1 for cases: Adjusted data reported by countries Method 2 for cases: Modelled relationship between malaria transmission, case incidence and intervention coverage Method 1 for deaths: Fixed case fatality rate applied to case estimates Method 2 for deaths: Modelled relationship between malaria transmission, malaria mortality and intervention coverage See World Malaria Report 2011 for more details of methods used 2 South Sudan became a separate State on 9 July 2011 and a Member State of WHO on 27 September 2011. South Sudan and Sudan have distinct epidemiological proles comprising high-transmission and low-transmission areas respectively. For this reason data up to June 2011 from the high-transmission areas of Sudan (10 southern states which correspond to South Sudan) and low-transmission areas (15 northern states which correspond to contemporary Sudan) are reported separately. 3 Estimates for Sudan in 2010 include only the 15 northern states now known as Sudan and the 10 southern states now South Sudan

224 | WORLD MALARIA REPORT 2013

Reported malaria cases Malaria case denition C P+C S P+C P+C C C C C C C P+C P+C P+C C P+C P+C P+C C C P+C P+C P+C P+C C S C C P+C P+C P+C Mic. slides/ RDTs performed 1186179 68 2000700 835624 497040 1046 18268 209239 337830 805761 289562 42512 39238 122159270 1900725 1423966 175252 948250 1130757 181917 189186 6918657 369359 1566872 385352 332063 555 216607 33273 3412455 Mic. slides/ RDTs positive 3406 18842 225371 616965 109908 4 5 3 33 376 1 9901 82 21850 1067824 417819 480586 2092 93 32569 5211 40476 2603 46202 4725 150195 7133 555 24383 3435 19638 Mic. slides/ RDTs P. falciparum 1279 150563 1 3 1 2 131 1 9428 33 524370 199977 314676 612 41 11553 1962 14896 1419 37692 894 58747 4774 54 14748 1257 11448 Mic. slides/ RDTs P. vivax 2088 398 3 2 2 31 243 0 396 47 534129 187583 135388 1480 45 17506 2288 19575 1080 7634 1461 7108 2189 501 9339 1680 7220 Imported cases / (Introduced cases) 3324 1 4 /(1) 3 15 157 /(219) 1 0 70 924 /(35) 47 Cases at community level 812511 19617 0 38666 310 106081 953 1377 29104

Inpatient malaria cases and deaths Inpatient malaria cases 5 5852 107029 2106 1 5 3 21 1 1457 35 0 26881 93 75 3494 86 7087 935 9238 1220 353 1050 10563 Malaria attributed deaths 0 1321 618 72 0 0 0 0 0 11 1 0 519 252 403 0 0 37 3 45 14 44 12 301 16 0 18 8

aria nition

Mic. slides/ RDTs performed 80020812 7949104 11462000 1899047 128915293 10193841 241746009

Mic. slides/ RDTs positive 35736961 693449 1264670 110329 2032817 284918 40818085

Mic. slides/ RDTs P. falciparum 12425003 105497 111076 150701 1060691 136443 13989411

Mic. slides/ RDTs P. vivax 755856 307699 324808 679 876574 52855 2190147

Imported cases

Cases at community level 5128924 37200 990338 58283 108721 6352570

Inpatient malaria cases 5025603 13180 174367 32036 19969 5569234

Malaria attributed deaths 103672 453 2241 72 1223 453 106887

0 0 0 0 0 0 8302

WORLD MALARIA REPORT 2013 | 225

Annex 6B R  eported malaria cases by method of conrmation, 19902012

WHO Region African Country/area Algeria Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases 1990 152 243673 92870 10750 496513 92870 69 869048 174436 212554 32428 511916 25552 1991 229 1143701 118796 14364 448917 568938 80 787796 125038 246410 32391 466895 22598 1992 106 782988 290868 4995 420186 773539 38 664413 89930 229444 21121 553875 25100 206262 1993 84 722981 403327 55331 502275 828429 44 478693 82072 234869 12012 15504 421043 17867 305616 1994 206 667376 546827 29591 472355 831481 21 189066 82057 278225 13860 35957 14827 358469 1995 107 156603 579300 17599 501020 932794 127 784321 100962 293564 15707 28008 755812 12530 81183 412609 1996 221 623396 80004 582658 974226 77 931311 95259 278048 15509 14000 1109011 198064 129908 478411 1997 197 893232 670857 101887 672752 670857 20 787796 99718 343186 9491 983089 509804 1998 1169028 650025 59696 721480 687301 41 664413 105664 395205 3844 17122 141353 255150 604960

Angola

Benin

Botswana

Burkina Faso

Burundi

Cabo Verde

Cameroon

Central African Republic

Chad

Comoros

Congo

Cte d'Ivoire

Democratic Republic of the Congo

Equatorial Guinea

Eritrea

Ethiopia

226 | WORLD MALARIA REPORT 2013

1999 701 1471993 709348 72640 867866 1936584 29 127964 392815 9793 1508042 147062 647919

2000 541 27733 541 506 2080348 0 71555 8056 0 3076538 484249 308095 144 6843 144 15 0 89614 431836 45283 40078 0 0 0 961762 3758 897 0 0 0

2001 435 26411 435 427 1249767 717290 48281 4716 322581 30006 0 0 3149338 508558 312015 107 7141 107 7 0 140742 446289 43180 38287 0 0 1193288 2197534 3244 1531 0 125746 22637 9716 2555314 851942 392377

2002 307 18803 307 299 1862662 782818 28907 1588 1156074 32796 0 0 2423268 530019 327138 76 8022 76 18 0 0 516248 44689 43933 0 0 1109751 2638199 3704 1735 0 74861 52228 6078 2929685 1115167 427795

2003 427 17059 427 421 3246258 819256 23657 1830 1411928 31256 0 0 1996275 600369 353459 68 6001 68 20 0 78094 496546 54381 45195 0 0 1136810 4384256 4820 2438 0 65517 52428 10346 3582097 1010925 463797

2004 163 16686 163 160 2489170 853034 22404 3453 1512026 52874 18256 1505270 608017 363395 45 9833 45 13 0 129367 480957 1525 1360 43918 12874 0 1275138 4130878 5320 2684 0 27783 41361 4119 5170614 1312422 578904

2005 299 18392 299 297 2329316 889572 803462 11242 530 1563768 73262 21335 1757589 903942 327464 68 7902 68 14 277413 131856 496075 37439 31668 29554 6086 0 1280914 6332048 5531 2971 0 24192 48937 9073 3901957 1364194 538942

2006 117 13869 117 116 2283097 1029198 106801 53200 861847 23514 2548 1983085 122047 44265 1771257 1034519 649756 251925 141975 80 6979 80 1750 17 634507 114403 233614 62895 45155 54830 20559 157757 1253408 5006230 4779 2050 0 10148 46096 6541 3038565 785209 447780

2007 288 14745 288 261 2295136 1458123 1295535 506756 237950 1171522 16983 14200 381 113 9 2404759 127120 44246 1363360 1411407 860606 406738 241038 18 7402 18 1500 16 604153 313083 119477 502236 64884 48288 53511 103213 163924 103213 1277670 3277830 1181323 740615 2275 243 15828 10752 5842 655 445 19568 68905 9528 7520 6037 2557152 739627 451816

2008 196 11964 196 192 2151072 2118053 1106534 541291 271458 1147005 17886 23253 914 941 13 3688338 138414 36514 1334939 1161153 690748 330915 185993 35 7033 35 2000 19 1650749 152260 462573 64171 47757 46426 117291 203869 117291 1327520 19661 3527 3938597 2613038 1618091 428 127 62312 11815 7883 2572 1620 10572 54075 4364 6566 4400 2532645 986323 458561

2009 94 15635 94 90 2221076 2172036 1120410 906916 453012 1256708 0 534590 355007 14878 17553 951 1053 73 4399837 137632 59420 182658 123107 1764343 1537768 893314 472341 292308 65 65 21913 1883199 0 0 175210 474257 74791 49679 13387 5982 92855 203160 92855 1820000 34755 7388 6749112 2956592 1873816 12436 4889 78983 15960 11603 3773 2581 21298 68407 6633 0 5126 3043203 2065237 927992 262877 108324

2010 408 12224 408 396 2783619 1947349 1324264 639476 358606 1432095 12196 1046 5409156 177879 88540 940985 715999 2919866 2825558 1599908 273324 163539 47 47 29 1845691 66484 345015 89749 75342 309927 125106 47364 87595 35199 5249 1339 446656 1721461 62726 7937162 3678849 2374930 54728 42850 72551 42585 39636 16772 14177 53750 79024 13894 0 22088 4068764 2509544 1158197

2011 191 11974 191 187 2534549 1765933 1147473 833753 484809 1283183 88134 68745 475986 354223 1141 432 167 3 4602524 400005 83857 450281 344256 1829644 2859720 1485332 181489 86542 36 26508 36 598492 1110308 120466 221980 528454 86348 114122 94778 24856 63217 22278 20226 2578 277263 114678 71048 0 0 2568152 49828 29976 6865504 4226533 2700818 2912088 1861163 33830 23004 20601 2899 1865 39567 67190 15308 25570 19540 3549559 3418719 1480306

2012 887 15790 887 828 1496834 2245223 1056563 1069483 440271 1151038 243008 0 825005 705839 308 193 81 4 6089101 223372 90089 4516273 3767957 2151076 2659372 1484676 1148965 666400 8751 8715 36 35 313315 1182610 93392 451012 55746 46759 590786 69789 49840 125030 45507 27714 4333 117640 6006 3717 0 0 2168215 195546 107563 1572785 1033064 6263607 4329318 2656864 3327071 2134734 15169 33245 13196 6826 1973 42178 84861 11557 33758 10258 3876745 3778480 1692578

WORLD MALARIA REPORT 2013 | 227

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region African Country/area Gabon Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases 1990 57450 222538 1438713 21762 81835 3870904 248904 26903 1162824 1116992 1282012 1991 80247 215414 1372771 17718 64123 282256 42112 808968 909656 1331494 1992 100629 188035 1446947 56073 280562 45687 865976 1219348 1373247 1993 70928 1697109 158748 4686201 295737 43892 380530 726666 981943 733203 1994 82245 299824 1672709 607560 6103447 4736974 263100 156080 401519 806204 1175004 371550 1995 54849 135909 1928316 600317 197386 4343190 196358 95357 214478 275442 778175 1133926 1391931 1996 74310 266189 2189860 772731 6457 3777022 239998 6183290 29818 181204 12794 345177 1162824 1149435 1145759 1997 57450 325555 2227762 802210 10632 826151 2761269 384907 189571 390601 978855 1148542 1331494 1998 80247 1745214 817949 2113 80718 777754 2985659 12234 168131 194024 353110 872925 2122663 1279581

Gambia

Ghana

Guinea

Guinea-Bissau

Kenya

Liberia

Madagascar

Malawi

Mali

Mauritania

Mayotte

Mozambique

Namibia

Niger

Nigeria

Rwanda

228 | WORLD MALARIA REPORT 2013

1999 127899 2895079 807895 197454 122792 1141474 4193145 530197 253513 2336640 429571 815895 1965486 906552

2000 127024 50810 0 3349528 816539 4800 246316 4216531 0 1367854 31575 6946 3646212 546634 0 0 0 0 2476608 0

2001 132918 53167 481590 3044844 851877 6238 202379 3262931 0 1361475 33354 8538 3823796 612896 243942 0 538512 41636 1340142 2253519 150 1003793 748806 423493

2002 157440 62976 620767 3140893 850147 16561 194976 3295805 43643 20049 0 1576439 27752 5272 2784001 723077 224614 0 445803 23984 888345 2605381 380 1073546 951797 506028

2003 166321 58212 540165 3552896 731911 107925 162344 5280498 96893 39383 0 2167873 37333 6909 3358960 809428 318120 792 792 0 468259 20295 681783 56460 2608479 1217405 1071519 553150

2004 170182 100107 70075 395043 3416033 475441 876837 103069 187910 7513874 59995 28328 0 1426872 39174 7638 2871098 1969214 224840 743 743 0 610799 36043 754934 81814 76030 3310229 1303494 1201811 589315

2005 176610 129513 70644 329426 3452969 655093 0 850309 50452 166431 33721 14659 9181224 44875 8718 5025 57325 39850 1198195 37943 6753 3688389 962706 223472 500 500 0 339204 23339 745428 107092 46170 21230 9873 3532108 1654246 1438603 683769

2006 33458 136916 33458 427598 3511452 472255 0 834835 41228 16554 12999 128978 34862 15120 8926058 886543 165095 115677 880952 645738 1063934 29318 5689 4498949 1022592 158073 31013 1061 560 392 88 0 265595 27690 790817 87103 12567 3956 3982372 1429072 1523892 573686

2007 93529 142406 45186 439798 3123147 0 476484 888643 28646 21150 15872 120105 34384 14284 9610691 553774 123939 80373 508987 411899 578175 30921 4823 175595 43674 4786045 1291853 222476 562 421 136 6155082 141663 172024 4242 249027 1308896 55628 1308896 193399 2969950 946569 1754196 382686

2008 77278 151137 40701 508846 39164 3050513 1100238 956359 143879 138124 657003 33405 128758 31083 11299 839904 839904 606952 238752 157920 635855 449032 116538 30566 4096 299000 89138 5185082 1045424 199791 835 268 720 34 411 346 155 4831491 120259 132130 24361 1092 0 0 496858 2229812 62243 530910 434615 2834174 143079 772197 1640106 316242

2009 112840 1623 660 479409 50378 1899544 2431048 962599 468449 141771 812471 20932 20866 14909 143011 25379 11757 25000 8123689 871560 327392 212657 676569 626924 215110 23963 2720 610035 212390 6183816 1633423 167705 3717 603 4338 337 399 352 268 4310086 93874 87402 16059 505 0 0 309675 2358156 79066 312802 230609 4295686 335201 144644 1247583 2637468 698745

2010 136440 54714 12816 7887 1120 194009 290842 52245 123564 64108 2642221 2031674 1029384 247278 42253 1092554 20936 85280 48799 30239 56455 20152 4585712 2384402 898531 2263973 335973 212927 998043 709246 202450 24393 2173 604114 200277 6851108 1018846 1380178 227482 238565 5449 909 2299 1085 433 2023 396 236 1522577 1950933 644568 2287536 878009 25889 14522 556 0 0 620058 165514 49285 7426774 570773 3873463 523513 45924 27674 638669 2708973 638669

2011 178822 261967 172241 71588 190379 3240791 1172838 624756 781892 416504 1101975 43549 5450 139066 90124 71982 57698 21320 139531 50662 9114566 3009051 1002805 2074391 728443 577641 1593676 1338121 224498 34813 3447 739572 221051 4942496 119996 50526 580708 253973 1293547 974558 307035 145186 3752 1130 7991 1796 97 1214 92 52 1756874 2504720 1093742 2966853 663132 14406 13262 335 48599 1525 2677186 130658 68529 1130514 712347 3392234 672185 242526 208498 1602271 208858

2012 137695 66018 18694 4129 1059 271038 156580 29325 705862 271038 8774516 4219097 2971699 1438284 783467 1220574 191421 125779 50381 61048 23547 97047 26834 5788381 4836617 1426719 164424 26752 1407455 772362 507967 1276521 899488 359420 38453 3667 906080 355753 3659565 406907 283138 2763986 1281846 2171739 0 97995 788487 165834 1865 255 3293 1633 72 1463 72 47 1813984 2546213 886143 2234994 927841 3163 7875 194 0 0 3525112 120528 84234 1084748 758109 2087068 1953399 2898052 483470 2904793 422224 190593 61246

WORLD MALARIA REPORT 2013 | 229

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region African Country/area Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Senegal Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Sierra Leone Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases South Africa Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Swaziland Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Togo Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Uganda Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases United Republic of Presumed and conrmed Microscopy examined Tanzania Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed United Republic Microscopy examined of Tanzania Conrmed with microscopy (Mainland) RDT examined Conrmed with RDT Imported cases United Republic of Presumed and conrmed Tanzania (Zanzibar) Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Zambia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Zimbabwe Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Argentina Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Bahamas Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Belize Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Bolivia Microscopy examined (Plurinational Conrmed with microscopy State of ) RDT examined Conrmed with RDT Imported cases Brazil Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Sao Tome and Principe 1990 6822 810509 10715736 1933696 662613 1660 22624 1660 4 4 4 3033 17204 3033 19680 121743 19680 560396 3294234 560396 1991 4693 780825 8715736 2340994 581168 803 16844 803 3 3 3 3317 25281 3317 19031 125509 19031 614431 3283016 614431 1992 2872 634166 2446659 7681524 2953692 420137 643 13619 643 2 2 2 5341 24135 5341 24486 125414 24486 609860 2955196 609860 1993 13285 561328 1470662 8777340 3514000 877734 758 11389 758 2 2 2 8586 47742 8586 27475 125721 27475 483367 2551704 483367 1994 450071 10289 328488 2191277 7976590 3514000 324188 948 14070 948 0 0 0 10411 50740 10411 34749 128580 34749 564406 2671953 564406 1995 51938 628773 8750 1431068 2438040 2742118 761791 1065 12986 1065 3 3 3 9413 37266 9413 46911 152748 46911 565727 2582017 565727 1996 47074 7192 27035 38875 352334 4969273 3215866 1696192 2048 12833 2048 0 0 0 6605 35113 6605 64012 161077 64012 455194 2159551 455194 1997 47757 861276 209312 23121 23754 366672 2317840 1131655 1849383 592 9684 592 8 8 8 4014 26598 4014 51478 141804 51478 405051 1869382 405051 1998 46026 948823 249744 26445 4410 368472 2845811 3399630 1719960 339 9341 339 21 21 14 2614 27000 2614 73913 176023 73913 469982 2089175 469982

Region of the Americas

230 | WORLD MALARIA REPORT 2013

1999 37026 1145112 409670 51444 30420 412619 3070800 423967 3385616 1804479 222 8524 222 30 30 21 1855 19395 1855 50037 159618 50037 609594 2435451 609594

2000 32149 66076 31975 1168336 56169 44959 460881 64624 29374 0 0 0 0 17734 53533 17734 0 17734 53533 17734 3337796 0 440 7949 440 2 22 2 2 1486 18559 1486 31469 143990 31469 613241 2562576 613241

2001 44034 83045 42086 881917 55494 12920 445047 4985 2206 26506 26506 12854 24123 1395 498826 678791 58689 354207 53804 38537 324584 20152 18385 53804 18385 3838402 0 215 6685 215 4 4 4 1162 18173 1162 15765 122933 15765 388303 2274610 388303

2002 50953 93882 50586 912581 54257 14425 500227 10605 3702 15649 15649 10129 13997 670 583872 655972 194736 67953 332477 123352 42468 323495 71384 25485 16983 51968 16983 3760335 125 5043 125 1 1 1 1134 15480 1134 14276 137509 14276 348259 2118491 348259

2003 47830 81372 42656 1329015 85246 26865 516634 12298 3945 13459 13459 7203 12564 342 490256 18088590 8647075 3937523 9044858 4350487 1976614 9043732 4296588 1960909 15705 53899 15705 4346172 122 3977 122 3 34 3 3 1084 15480 1084 20343 158299 20343 408886 2009414 408886

2004 53991 97836 46486 1171799 67750 22234 352859 4985 2206 13399 13399 5140 6754 574 516942 17713004 11108844 4992828 8852865 5579910 2502382 8860139 5528934 2490446 11936 50976 11936 4078234 1815470 215576 33980 115 3018 115 2 17 2 2 1066 17358 1066 14910 163307 14910 5000 465004 2194780 465004

2005 22370 68819 18139 1379318 105093 33160 224584 10605 3702 3452 1106 7755 7755 6066 4587 279 437662 12397268 16031596 5520470 6193143 8037619 2764049 6204125 7993977 2756421 7628 43642 7628 4121356 1494518 253280 37908 252 3018 252 1 9 1 1 1549 25119 1549 20142 202021 20142 6000 1300 606067 2660539 606067

2006 7293 58672 5146 1594616 138254 48070 148625 12298 3945 4675 987 14456 12098 7807 3985 155 566450 16700366 8303450 3855007 8343841 4167063 1928296 8356525 4136387 1926711 1585 30676 1585 4731338 1313458 219344 39404 212 6353 212 49 546 49 30 844 25755 844 18995 208616 18995 6000 730 549469 2959489 549469

2007 2421 49298 2421 1002918 195487 78278 90161 40054 653987 6327 6327 6338 0 84 516640 231860 117720 188225 103390 11525127 9300453 3691541 5755774 4661982 1845917 5769353 4638471 1845624 293 23511 293 4248295 0 0 1154519 234730 116518 387 6353 387 6 6 5 845 22134 845 0 14610 180316 14610 1500 458652 2986381 458652 0

2008 1647 38583 1647 140478 4611 443828 48324 24830 487188 217096 851478 471600 154459 235800 154459 7796 7796 5881 0 58 602908 321171 152724 318895 192138 7621061 7674717 3808778 3843950 67 3812283 3830767 4585 56579 77 173311 4508 3080301 0 0 1003846 59132 16394 59132 16394 130 5157 130 14 35 14 2 540 25550 540 0 9748 159826 9748 5000 6 315746 2726433 315746 0

2009 6182 59228 3798 60649 2384 222232 43026 19614 485548 146319 646808 770463 273149 544336 373659 6117 6072 3313 6624 0 106 1 1 618842 420053 192966 314250 198372 25413642 12661552 60691 211 121248 3031 12752090 3242 60691 211 121248 3031 2976395 0 0 736897 122133 57014 122133 57014 86 86 0 256 26051 256 0 0 9743 132633 9234 981 509 309316 2620787 309316 90275

2010 3346 48366 2233 9989 507 371912 27793 17750 651737 325920 934028 718473 218473 1609455 715555 8060 15900 3787 276669 4273 4185 1722 0 87 767 181 617101 478354 224087 575245 393014 20920893 7211369 2553684 10398751 3637659 1277024 136123 1974 10522142 3573710 1276660 2338 63949 364 136123 1974 4229839 648965 0 0 513032 249379 72 2547 72 46 1 27272 1 0 0 1 150 27366 150 0 0 13769 133463 12252 7394 1517 21 334668 2711432 334667 1 1

2011 8442 83355 6373 33924 2069 299788 18325 14142 556787 262100 638859 46280 25511 886994 613348 9866 178387 5986 204047 3880 797 0 130 2223 419 519450 502977 237305 390611 282145 10508198 11170526 3625883 2943754 671150 5030729 5656907 1813179 1628092 337582 5477469 5513619 1812704 1315662 333568 4489 143288 475 312430 4014 4607908 319935 10004 0 470007 319935 18 7872 18 18 6 31013 6 0 0 6 79 22996 79 0 0 7143 143272 6108 7390 1035 17 267146 2476335 266713 1486 433

2012 12550 103773 10706 23124 1844 366912 19946 11905 532694 270053 1537322 194787 104533 1975972 1432789 6846 121291 1632 30053 3997 626 0 78 1070 217 697374 579507 260535 660627 436839 10338093 3466571 1413149 2449526 1249109 2441750 6931025 1772062 1091615 214893 2972186 6784639 1771388 701477 212636 2931 146386 674 390138 2257 4695400 276963 0 0 727174 276963 4 7027 4 4 0 37 20789 37 0 0 7415 121944 6293 10960 1122 242758 2325775 237978 23566 4780

WORLD MALARIA REPORT 2013 | 231

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region Region of the Americas Country/area Colombia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases 1990 99489 496087 99489 1151 113167 1151 356 297599 356 71670 363080 71670 9269 230246 9269 5909 49192 5909 41711 305791 41711 22681 135260 22681 4806 13743 4806 53099 418513 53099 0 281 0 0 44513 1503208 44513 35785 466558 35785 381 315359 381 2912 98417 2912 28882 90040 28882 1608 18594 1608 1991 184156 740938 184156 3273 130530 3273 377 343491 377 59400 346465 59400 5951 190540 5951 3573 55242 3573 57829 361743 57829 42204 141046 42204 25511 81763 25511 73352 468811 73352 3 3 3 26565 1596427 26565 27653 364786 27653 1115 336569 1115 2983 127807 2983 33705 109654 33705 1490 18399 1490 1992 184023 736498 184023 6951 149198 6951 698 299549 698 41089 377321 41089 4539 202446 4539 4072 56925 4072 57560 396171 57560 39702 159108 39702 13457 37957 13457 70838 471950 70838 6 6 6 16170 1668729 16170 26866 381715 26866 727 308359 727 1289 149523 1289 54922 123147 54922 1404 13765 1404 1993 129377 656632 129377 5033 140435 5033 987 290073 987 46859 419590 46859 3887 172624 3887 3974 49993 3974 41868 276343 41868 33172 172469 33172 853 10045 853 51977 372180 51977 6 6 6 15793 1816340 15793 44037 440891 44037 481 278557 481 147 436 164146 436 98557 158325 98557 6107 26079 6107 1994 127218 572924 127218 4445 143721 4445 1670 316182 1670 30006 301546 30006 2803 139587 2803 4241 48242 4241 22057 133611 22057 39566 168127 39566 23140 54973 23140 61736 361776 61736 3 3 3 12864 1923775 12864 41490 374348 41490 735 237992 735 130 583 96885 583 122039 295824 122039 4704 29148 4704 1995 187082 667473 187082 4515 143408 4515 1808 380143 1808 18128 253714 18128 3364 169267 3364 4711 52521 4711 24178 135095 24178 59311 291370 59311 74346 373364 74346 5 5 5 7423 1965682 7423 69444 493399 69444 730 222498 730 10 898 86664 898 190521 833614 190521 6606 38613 6606 1996 135923 461137 135923 5480 148161 5480 1414 436473 1414 11914 162128 11914 5888 164491 5888 4724 46780 4724 20268 97586 20268 34075 262526 34075 18877 69853 18877 91799 305167 91799 14 206 14 14 6293 2053773 6293 75606 461989 75606 476 188914 476 637 68151 637 211561 1162230 211561 16649 68674 16649 1997 180898 583309 180898 4712 155925 4712 816 446874 816 16365 174692 16365 2719 166895 2719 3195 42631 3195 32099 140113 32099 32103 229710 32103 5870 35132 5870 67870 310815 67870 4 110 4 4 5046 1950935 5046 51858 410132 51858 505 193853 505 567 83104 567 180338 1299929 180338 11323 94508 11323 1998 190553 190553 5148 103976 5148 2006 453850 2006 43696 300752 43696 1182 161900 1182 3462 3462 46765 46765 41200 296596 41200 34449 34449 44337 249105 44337 3 207 3 3 25023 1806903 25023 34108 440312 34108 1039 187055 1039 2091 42944 2091 247229 1942529 247229 12412 73481 12412

Costa Rica

Dominican Republic

Ecuador

El Salvador

French Guiana, France

Guatemala

Guyana

Haiti

Honduras

Jamaica

Mexico

Nicaragua

Panama

Paraguay

Peru

Suriname

232 | WORLD MALARIA REPORT 2013

1999 66845 268355 66845 3998 96454 3998 3589 453720 3589 87620 444606 87620 1230 144768 1230 5307 47974 5307 45723 192710 45723 27283 255228 27283 1196 1196 51911 250411 51911 5 219 5 5 13450 1906050 13450 38294 555560 38294 936 161219 936 6 9946 101074 9946 161292 2027624 161292 13939 65087 13939

2000 144432 478820 144432 1879 61261 1879 1233 427297 1233 0 0 322 104528 544646 104528 753 279072 753 3708 48162 3708 53311 246642 53311 24018 209197 24018 16897 21190 16897 35125 175577 35125 7 874 7 7 7390 2003569 7390 23878 509443 23878 1036 149702 1036 23 6853 97026 6853 68321 1483816 68321 11361 63377 11361

2001 231233 747079 231233 1363 43053 1363 1038 411431 1038 0 0 210 108903 538757 108903 362 111830 362 0 0 3823 44718 3823 35824 198114 35824 27122 211221 27122 9837 51067 9837 24149 174430 24149 6 596 6 6 4996 1857233 4996 10482 482919 10482 928 156589 928 22 2710 71708 2710 78544 1417423 78544 16003 67369 16003

2002 204916 686635 204916 1021 17738 1021 1296 391216 1296 0 0 507 86757 403225 86757 117 115378 117 0 0 3661 44718 3661 35540 197113 35540 21895 175966 21895 17223 178616 17223 7 725 7 7 4624 1852553 4624 7695 491689 7695 2244 165796 2244 2778 99338 2778 99237 1582385 99237 12837 68070 12837

2003 180956 640453 180956 718 9622 718 1529 349717 1529 0 0 532 52065 433244 52065 85 102053 85 0 0 3839 32402 3839 31127 156227 31127 27627 185877 27627 14063 137522 14063 9 394 9 9 3819 1565155 3819 6717 448913 6717 4500 166807 4500 26 1392 126582 1392 88408 1485012 88408 10982 43241 10982

2004 142241 562681 142241 1289 9204 1289 2355 322948 2355 0 0 524 28730 357633 28730 112 94819 112 0 0 3038 32402 3038 28955 148729 28955 28866 151938 28866 10802 30440 10802 17134 144516 17134 141 3879 141 141 3406 1454575 3406 6897 492319 6897 5095 171179 5095 26 694 97246 694 93581 1438925 93581 8378 56975 8378

2005 121629 493562 121629 3541 12767 3541 3837 397108 3837 0 0 1376 17050 358361 17050 67 102479 67 0 0 4 3414 32402 3414 39571 178726 39571 38984 210429 38984 21778 3541506 21778 15943 152557 15943 2500 88 2470 88 88 2967 1559076 2967 6642 516313 6642 3667 208582 3667 20 376 85942 376 87699 1438925 87699 9131 59855 9131

2006 120096 451240 120096 2903 24498 2903 3525 446839 3525 0 0 1031 9863 318132 9863 49 113754 49 0 0 4074 32402 4074 31093 168958 31093 21064 202688 21064 32739 87951 32739 11947 125266 11947 2500 194 6821 194 8 2514 1345915 2514 3114 464581 3114 11563 1663 212254 1663 12 823 111361 823 64925 1438925 64925 3289 45722 3289

2007 125262 564755 125262 25000 3200 1223 22641 1223 0 0 2711 435649 2711 0 0 518 8464 352426 8464 40 95857 40 18 4828 32402 2797 2031 15382 129410 15382 3000 11656 178005 11656 0 0 29825 142518 29825 1 10512 130255 10512 199 199 8 2361 1430717 2361 0 0 1356 521464 1356 16173 0 1281 204193 1281 0 0 16 1341 92339 1341 0 0 50797 1438925 50797 1104 31768 1104 2224 637

2008 79230 470381 79230 22754 1329 58 966 17304 966 0 0 1840 381010 1840 0 0 172 4891 384800 4891 2758 33 97872 33 12 3265 11994 1341 0 1979 7198 173678 7198 2000 5 11815 137247 11815 0 0 41 36774 168950 36774 5 8368 119484 8368 0 22 30732 22 4 2357 1246780 2357 0 0 762 533173 762 10000 0 744 200574 744 0 0 12 341 94316 341 1997 7 8 44522 796337 44522 64953 2086 28137 2086 1774 623 635

2009 79347 428004 79252 8362 95 262 4829 262 0 0 1643 353336 1643 0 0 149 4120 446740 4120 4992 20 83031 20 0 0 10 3462 20065 1433 0 2029 7080 154652 7080 2000 13673 169309 13673 0 0 45 49535 270438 49535 9313 108522 9313 4000 0 22 34149 22 7 2703 1240087 2703 0 0 610 544717 610 9000 0 10 778 158481 778 0 0 8 91 64660 91 0 0 12 42645 42645 2499 33279 1842 1438 538 1176

2010 117650 521342 117637 13 114 15599 114 0 0 4 2482 469052 2482 26585 932 461 1888 481030 1888 7800 17 24 115256 24 0 0 7 1608 14373 688 944 7198 235075 7384 2000 0 22935 212863 22935 0 0 84153 270427 84153 0 0 9685 148243 9685 4000 1 12 10763 12 0 0 10 1226 1192081 1226 0 0 7 692 535914 692 18500 0 7 418 141038 418 0 0 5 27 62178 27 0 0 9 31545 744627 31545 23 1 1771 16533 1574 541 138 1032

2011 64436 396861 60121 21171 4188 17 10690 17 6 1616 421405 1616 56150 577 1233 460785 1233 14 15 100883 15 1 1 6 1209 14429 505 704 6817 195080 6817 0 0 0 29471 201693 29471 35 35 119 32969 180227 32969 0 0 7615 151785 7615 4000 45 9 5042 9 0 0 8 1124 1035424 1124 6 925 521904 925 14021 0 354 116588 354 0 0 9 10 48611 10 10 24989 702894 25005 58 34 795 15135 730 135 20 538

2012 60179 346599 50938 70168 9241 8 7485 8 1 952 415808 952 90775 349 558 459157 558 14 19 124885 19 6 900 13638 401 499 5346 186645 5346 0 0 1 31601 196622 31546 55 48 25423 161236 25423 0 0 6434 137165 6434 4000 10 2 5 3687 5 0 0 5 833 1025659 833 9 1235 536278 1235 16444 0 0 844 107711 844 0 0 8 15 31499 15 15 31436 758723 31436 562 134 569 17464 295 3346 50

WORLD MALARIA REPORT 2013 | 233

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region Region of the Americas Country/area Presumed and conrmed Venezuela (Bolivarian Republic Microscopy examined Conrmed with microscopy of ) RDT examined Conrmed with RDT Imported cases Afghanistan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Djibouti Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Egypt2 Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Iran (Islamic Presumed and conrmed Microscopy examined Republic of ) Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Iraq Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Morocco1 Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Oman Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Pakistan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Saudi Arabia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Somalia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases South Sudan* Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Sudan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Syrian Arab Presumed and conrmed Microscopy examined Republic2 Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Yemen Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Armenia1 Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Azerbaijan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases 1990 46679 361194 46679 317479 735624 317479 3237 11463 3237 75 1145251 75 0 77470 2226412 77470 6701 3924 3924 837 1347400 837 51 32720 270748 32720 79689 2608398 79689 15666 682649 15666 634 7508704 330136 107 107 39 11384 80986 11384 0 0 0 0 24 24 0 1991 42826 375473 42826 297605 768685 297605 7338 26758 7335 24 1213769 24 0 96340 2699845 96340 8431 1764 941988 1764 20 494 982321 494 89 19274 250447 19274 66586 271586 66586 9962 570551 9962 830 6947787 321969 54 54 43 12717 103700 12717 0 0 0 0 113 113 0 1992 21416 336571 21416 7468 28636 7468 16 1183608 16 0 76971 3227770 76971 12024 5752 1166378 5752 42 405 898625 405 54 14827 211887 14827 99015 2668997 99015 19623 601847 19623 1204 9326944 1167847 456 456 37 29320 126580 29320 0 0 0 0 27 27 0 1993 12539 290483 12539 123425 431353 123425 4166 17 562096 17 0 64581 3959288 64581 8162 49863 198 761837 198 63 16873 251630 16873 92634 2615771 92634 18380 18380 3049 6467 3049 9867778 923374 966 966 31262 172403 31262 0 0 0 23 23 0 1994 16311 210890 16311 88302 626338 31606 6140 25366 6140 527 1052433 495 32 51089 4074869 51089 7052 98243 1553231 98243 21 206 724364 206 50 7215 295194 7215 2800 108586 2796528 108586 10032 697960 10032 3405 8562205 664491 583 97436 583 49 37201 160687 37201 196 196 0 195 667 667 0 1995 22501 302487 22501 186912 602320 186912 5982 322 9 67532 67532 98705 6 197 1047890 197 31 1801 464091 1801 637 111836 111836 18751 727703 18751 3089 6347143 656978 626 626 44 500000 500000 502 502 0 502 2840 2840 0 1996 21852 285326 21852 303955 364948 78279 6105 25 1090924 23 2 56362 3556000 56362 49840 1650864 31737 4 102 461605 102 49 1265 531123 1265 662 98035 2711179 98035 21007 21007 5786 4595092 30217 345 84496 345 65 416246 416246 347 347 0 198 13135 13135 0 1997 22400 271989 22400 202767 527181 189898 4314 4314 11 1052658 11 7 38684 3244334 38677 18852 13959 1480948 9594 29 125 461802 125 49 1026 485184 1026 897 77480 2914056 77480 20631 20631 2939 4065460 446949 130 68154 130 47 1394495 7821530 682153 841 841 0 274 9911 9911 0 1998 21815 333786 21815 288070 272115 5920 13 13 13 32951 32951 11558 9684 9684 121 421946 121 53 1093 438166 1093 979 73516 3187814 73516 40796 795135 40796 4657 5062000 821199 60 60 46 1156 1156 0 614 5175 5175 0 0

Eastern Mediterranean

European

234 | WORLD MALARIA REPORT 2013

1999 19086 218959 19086 395581 463032 162531 6140 61 61 61 23110 2014963 23110 7253 4138 4138 60 376920 60 43 901 496067 901 872 91774 3440986 91774 13166 13166 3067 9055 4215308 594927 43 43 38 2781640 2781640 616 616 0 287 2315 2315 0 4

2000 29736 261866 29736 203911 257429 94475 4667 17 1155904 17 17 19716 1732778 19716 7422 1860 1860 59 277671 56 56 694 494884 694 688 3337054 82526 6608 6608 1872 10364 4332827 368557 42 42 36 1394495 1394495 141 356 141 0 85 1526 527688 1526 0

2001 20006 198000 20006 364243 4312 11 1357223 11 11 19303 1867500 19303 10379 1265 997812 1265 59 335723 59 59 635 521552 635 633 3577845 3572425 125292 3074 821860 3074 1471 10364 237712 3985702 203491 79 79 16 79 174 79 0 48 1058 536260 1058 3

2002 29491 278205 29491 626839 415356 5021 10 1041767 10 10 15558 1416693 15558 6436 952 1072587 952 107 345173 107 88 590 495826 590 584 4238778 3399524 107666 2612 825443 2612 1402 96922 21350 15732 462056 3054400 280550 27 27 12 187159 556143 75508 52 165 52 0 36 506 507252 506 1

2003 31719 344236 31719 585602 360940 5036 5036 45 45 45 23562 1358262 23562 6502 347 681070 347 3 73 405800 73 69 740 409532 740 734 4210611 4577037 125152 2592 1724 819869 1724 1024 23349 12578 7571 646673 3084320 933267 24 24 22 265032 398472 50811 29 126 29 0 21 482 536822 482 2

2004 46655 420165 46655 273377 248946 242022 2142 122 43 43 43 13821 1326108 13821 6219 155 913400 155 5 56 405601 56 55 615 326127 615 615 1958350 4243108 126719 1101 1232 780392 1232 924 36732 30127 11436 515958 2083711 537899 13 13 12 158561 501747 48756 47 220 47 0 41 386 545145 386 0

2005 45049 420165 45049 326694 338253 116444 2469 1913 413 23 23 23 18966 1674895 18966 4570 47 944163 47 10824 0 3 100 100 100 544 258981 544 544 4022823 4776274 127826 290 1059 715878 1059 852 28404 47882 12516 337582 2515693 628417 28 28 28 200560 472970 44150 7 209 7 0 4 242 515144 242 0

2006 37062 479708 37062 414407 460908 86129 6457 1796 29 29 29 15909 1131261 15909 2782 24 970000 24 1 83 83 83 443 242635 443 443 4314637 4490577 124910 1149 1278 804087 1278 1008 49092 16430 116473 2117514 721233 34 34 34 217270 799747 55000 230 230 0 0 0 143 498697 143 2

2007 41749 392197 41749 4141 506 456490 504856 92202 4694 3461 210 30 23402 30 30 15712 1074196 15712 2434 3 844859 3 1 75 367705 75 75 705 244346 705 701 4553732 4905561 128570 190 2864 1015781 2864 2397 50444 16675 101008 3040181 2243981 686908 37 68000 37 37 223299 585015 67607 303 70 1 658 1 0 1 110 465033 110 2

2008 32037 414137 32037 554 467123 549494 81574 3528 2896 119 80 34880 80 80 11460 966150 11460 3111 6 1105054 6 4 142 292826 142 142 965 245113 965 957 4658701 3775793 104454 120 1491 1114841 1491 1430 82980 73985 36905 136492 116555 52011 3073996 2050354 569296 51 51 51 158608 781318 43545 5015 661 1 30761 1 0 1 73 408780 73 1

2009 35828 370258 35828 728 390729 521817 64880 2686 2686 94 41344 94 94 6122 744586 6122 1645 1 1493143 1 1 145 290566 145 145 898 234803 898 898 4242032 3655272 132688 243521 34891 2333 1078745 2333 2275 72362 59181 25202 325634 2361188 2791156 711462 39 25751 39 39 138579 797621 53445 18566 2001 0 31467 0 0 0 80 451436 80 0 2

2010 45155 400495 45155 0 814 392463 524523 69397 1010 1010 85 664294 85 85 3031 614817 3031 1184 7 1849930 7 7 218 232598 218 215 1193 226009 1193 1169 4281356 4281346 220870 279724 19721 1941 944723 1941 1912 24553 20593 5629 200105 18924 900283 900283 1465496 625365 1653300 95192 23 19151 23 23 198963 645463 78269 97289 28428 1 31026 1 1 52 456652 52 2

2011 45824 382303 45824 0 1080 482748 531053 77549 232 124 116 116 116 3239 530470 3239 1529 11 2097732 11 0 11 312 171400 312 312 1531 267353 1531 1518 4065802 4168648 287592 518709 46997 2788 1062827 2788 2719 41167 26351 1627 35236 1724 795784 112024 0 1246833 506806 48 25109 48 0 48 142147 645093 60207 108110 30203 0 0 8 449168 8 4

2012 52803 410663 52803 0 1539 391365 511408 54840 25 1410 22 0 3 206 818600 206 206 1629 479655 1629 842 8 1963638 8 8 364 285039 364 364 2051 2 051 2029 4285449 4497330 250526 410949 40255 3406 1186179 3406 3324 59709 34 18842 34 13 1125039 225371 964698 616965 2000700 42 19136 42 42 165678 685406 68849 150218 41059 0 4 497040 4 1

WORLD MALARIA REPORT 2013 | 235

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region European Country/area Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Kyrgyzstan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Russian Federation Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Tajikistan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Turkey Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases 1 Turkmenistan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Uzbekistan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Bangladesh Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Bhutan Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Democratic People's Republic Microscopy examined Conrmed with microscopy of Korea RDT examined Conrmed with RDT Imported cases India Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Indonesia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Myanmar Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Nepal Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Sri Lanka Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Thailand Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Timor-Leste Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Georgia 1990 1 1 0 1 1 1 0 1 216 216 0 209 0 0 5 1 1 1 28 28 25 2444415 53875 33973 9497 0 2018783 74420000 2018783 1484496 7365250 175049 989042 133049 847484 22856 287384 1220699 287384 273880 7273320 273880 1991 2 2 0 2 1 1 0 1 169 169 0 169 0 0 5 17 17 4 12 12 11 2081137 63575 67699 22126 0 2117460 75158681 2117460 1631710 7586249 140352 939257 1147570 126967 781543 29135 400263 1398002 400263 198383 6793221 198383 1992 1 1 0 1 2 2 0 2 160 160 0 160 0 0 11 11 11 6 25 25 25 1919349 115660 73986 28900 0 2125826 79011151 2125826 1431284 7501500 110004 789672 1038248 125710 724068 23234 399349 1558660 399349 168370 5575282 168370 1993 0 0 0 0 0 0 0 0 209 209 0 195 0 0 4 3 3 2 36 36 36 1635589 125402 78260 28116 0 2207431 77941025 2207431 1337373 6152901 146339 702239 898237 117068 596689 16380 363197 1503902 363197 115220 4850123 115220 1994 1 1 0 1 6 6 0 6 335 335 0 359 0 0 24 9 9 8 21 21 21 1661701 166564 97415 38901 0 2511453 82179407 2511453 1698040 4801009 146376 701043 734087 111672 430801 9884 273502 1370369 273502 102119 4756284 102119 1995 1 1 0 1 3 3 0 3 425 425 0 421 0 0 342 10 10 10 27 27 27 1461556 152729 83889 23195 0 2988231 85133349 2988231 1510425 2795718 143363 656547 600252 100448 338189 9718 142294 1098105 142294 82743 4569108 82743 1996 7 7 0 4 26 26 0 25 611 611 0 601 0 0 250 14 14 11 51 51 51 1112563 100783 76019 15696 0 3035588 91536450 3035588 1747287 3377083 179878 664507 486616 96203 204355 9020 184319 1288990 184319 87622 4318788 87622 1997 1 1 0 1 13 13 0 13 831 831 0 798 0 0 80 14 14 10 52 52 52 955542 68594 68153 9029 0 2660057 89445561 2660057 1325633 2815193 131084 568262 427288 112500 160253 126774 8557 218550 1331641 218550 97540 4068474 97540 1998 16 16 0 2 11 11 0 6 1081 1081 0 1018 0 0 62 137 137 22 74 74 74 437928 60023 62033 7693 2100 2100 2222748 89380937 2222748 1708020 2102828 179970 548066 450000 104753 175879 178265 8498 211691 1338146 211691 131055 4217716 131055 10332

South-East Asia

236 | WORLD MALARIA REPORT 2013

1999 51 51 0 16 5 5 0 5 792 792 0 715 0 0 55 49 49 39 85 85 78 378921 63723 77461 12237 15362 15362 2284713 88333965 2284713 1243213 1867488 138002 592878 379795 121376 132044 135814 8959 264549 1569352 264549 125379 4461075 125379

2000 173 245 0 1 12 70500 12 0 5 795 795 0 752 19064 233785 19064 11432 1597290 11432 0 51 24 50105 24 6 126 735164 126 80 437838 360300 55599 82380 76445 5935 204428 90582 2031790 86790375 2031790 1432178 1752763 245612 581560 381610 120083 48686 100063 7981 210039 1781372 210039 78561 4403739 78561 15212 15212

2001 438 3574 438 0 1 28 72020 28 0 13 898 898 0 764 11387 248565 11387 10812 1550521 10812 0 54 8 50075 8 3 77 691500 77 68 320010 250258 54216 71956 65974 5982 300000 143674 143674 2085484 90389019 2085484 2776477 1604573 267592 661463 463194 170502 146351 126962 6396 1198 66522 1353386 66522 63528 4100778 63528 83049

2002 472 6145 474 0 1 2743 69807 2743 0 31 642 642 0 503 6160 244632 6160 0 10224 1320010 10224 0 40 18 59834 18 3 74 735164 74 63 313859 275987 62269 81207 74696 6511 241192 129889 16578 1841227 91617725 1841227 2416039 1440320 273793 721739 467871 173096 133431 183519 12750 1280 41411 1390850 41411 44555 3819773 44555 86684 60311 26651

2003 315 5457 316 0 8 468 144070 468 0 3 533 533 0 461 5428 296123 5428 0 9222 1187814 9222 0 40 7 72643 7 1 74 812543 74 41 489377 245258 54654 65052 61246 3806 60559 32083 16538 1869403 99136143 1869403 2554223 1224232 223074 716806 481201 177530 196605 196223 9506 1132 10510 1192259 10510 37355 3256939 37355 33411 83785 33411

2004

2005

2006

2007 25 3400 25 0 1 96 62444 96 0 0 122 35784 122 0 112 635 159232 635 7 358 775502 358 0 45 0 65666 0 0 89 858968 89 59 59866 266938 58659 3199 1207 52239 51446 793 4795 7985 4795 450 1508927 86355000 1508927 8500000 1140423 1750000 333792 520887 512862 216510 499725 157448 135809 135809 5621 880 198 1047104 198 33178 2041733 33178 121905 114283 46869 32027 5944

2008

2009

2010

2011

2012

256 155 60 3365 5169 4400 257 155 60 0 0 0 3 1 2 93 226 318 79895 114316 74729 93 226 318 0 0 0 2 0 4 382 205 143 382 205 143 0 0 0 382 165 132 3588 2309 1344 272743 216197 175894 3588 2309 1344 0 1 1 5302 2084 796 1158673 1042509 934839 5302 2084 796 0 0 0 50 48 45 3 1 1 71377 56982 58673 3 1 1 0 0 1 66 102 76 893187 917843 924534 66 102 76 35 38 16 386555 290418 164159 185215 220025 209991 58894 48121 32857 57562 61977 67947 54892 60152 66079 2670 1825 1868 33803 11507 9353 27090 11315 12983 27090 11315 12983 1915363 1816569 1785109 97111526 104120792 106606703 1915363 1816569 1785109 3016262 1445831 1320581 1109801 1178457 1233334 268852 437323 347597 19164 12990 602888 516041 538110 432581 437387 485251 152070 165737 203071 140687 178056 166474 158044 188930 166476 4895 5050 4969 805 641 618 3720 1640 591 1198181 974672 1076121 3720 1640 591 26690 29782 30294 3012710 2524788 2280070 26690 29782 30294 202662 130679 164413 79459 97781 96485 39164 43093 37896

8 7 0 6 5 4398 4120 2368 2032 1046 8 7 0 6 5 0 0 2 6 0 5 4 18 4 6 5 3 40833 33983 30190 27850 18268 18 4 6 5 3 0 0 0 0 3 5 3 96 107 102 85 0 28340 27382 33024 28311 96 107 102 85 0 0 88 107 101 83 318 165 112 78 33 158068 165266 173523 173367 209239 318 165 112 78 33 4 1 1 13 15 215 84 78 128 376 616570 606875 507841 421295 337830 215 84 78 128 376 0 0 49 46 69 128 157 1 0 0 0 0 75524 94237 81784 1 0 0 1 0 0 0 27 4 5 1 1 883807 916839 921364 886243 805761 27 4 5 1 1 0 20 4 2 1 1 168885 79853 91227 51773 29518 336505 397148 308326 270253 253887 50004 25203 20519 20232 4016 106001 156639 152936 119849 35675 34686 38670 35354 31541 5885 450 1421 487 207 82 47268 62341 54709 44481 42512 329 972 436 194 82 0 16989 14845 13520 16760 21850 24299 34818 25147 26513 39238 16989 14845 13520 16760 21850 378 213 127 1127 1532497 1563574 1599986 1310656 1067824 86734579 103396076 108679429 108969660 109033790 1532497 1563574 1599986 1310656 1067824 9000000 9100000 10600000 10500384 13125480 746120 544470 1963807 2384260 2051425 1243744 1420795 1335445 962090 1429139 266277 199577 465764 422447 417819 462249 1040633 255734 250709 471586 72914 634280 591492 693124 567452 480586 499296 381424 275374 312689 265135 223174 164965 103285 91752 75220 543941 599216 729878 795618 1158831 223899 271103 317523 373542 405366 153331 123903 96383 71752 70272 153331 150230 102977 95011 152780 3888 3335 3115 1910 1659 17887 25353 22472 779 1504 433 660 610 1102 1126 670 558 684 175 93 1047104 909632 1001107 985060 948250 670 558 736 175 93 21 27 52 51 70 28569 29462 32480 24897 32569 1910982 1816383 1695980 1354215 1130757 26150 23327 22969 14478 32569 20786 68437 81997 96670 0 2419 6135 9511 10419 0 143594 108434 119072 36064 6148 92870 96828 109806 82175 64318 45973 41824 40250 19739 5211 30134 41132 85643 127272 117599 5287 5703 7887

WORLD MALARIA REPORT 2013 | 237

Annex 6B R  eported malaria cases by method of conrmation, 19902012 (continued)

WHO Region Western Pacic Country/area Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases China Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Presumed and conrmed Lao People's Microscopy examined Democratic Conrmed with microscopy Republic RDT examined Conrmed with RDT Imported cases Malaysia Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Papua New Guinea Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Philippines Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Republic of Korea Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Solomon Islands Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Vanuatu Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Viet Nam Presumed and conrmed Microscopy examined Conrmed with microscopy RDT examined Conrmed with RDT Imported cases Cambodia 1990 123796 117359 22044 50500 104900 86200 0 116500 28805 28805 123796 1991 102930 101600 41048 39189 86500 86400 0 141400 19466 19466 187994 1992 91000 74000 38500 36853 86500 95778 0 153359 13330 13330 225928 1993 99200 59000 41787 39890 66797 64944 1 126123 10469 10469 156069 1994 85012 62000 52601 58958 65000 61959 20 131687 3771 3771 140120 1995 76923 47118 52021 59208 99000 56852 107 118521 8318 8318 100116 1996 74883 33382 77894 51921 71013 40545 396 84795 5654 5654 84625 1997 88029 26800 72190 26649 38105 42005 1724 68125 6099 6099 65859 1998 58874 27090 39031 13491 20900 50709 3992 72808 6181 6181 72091

Regional Summary (presumed and conmed malaria cases)

African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic Total

15707308 12808592 16096895 20292113 27014847 21642318 28431539 22877000 26576925 1055674 1229551 1186061 1016131 1126125 1298690 1191309 1079831 1303387 8051292 7459945 9580797 10273192 8970329 7339807 5548379 5819082 5514224 271 314 226 271 1235 3808 14191 11663 7650 5053585 5287073 4914501 4725460 5286157 5380240 5719323 5030295 5009891 773900 806527 815248 664280 661128 618184 525108 435585 365167 30642030 27592002 32593728 36971447 43059821 36283047 41429849 35253456 38777244

Cases reported before 2000 can be presumed and conrmed or only conrmed cases depending on the country 1 Armenia, Morocco and Turkmenistan are certied malaria-free-countries, but are included in this listing for historical purposes 2 There is no local transmission * In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

238 | WORLD MALARIA REPORT 2013

1999 64679 26797 28050 11106 18564 37061 3621 63169 5152 5152 75102

2000 203164 122555 51320 18167 11122 0 279903 256273 40106 12705 1832802 12705 2002 1606187 225535 79839 36596 444668 36596 4183 4183 4183 41 368913 300806 68107 33779 31668 6768 274910 2682862 74316

2001 110161 121691 42150 23928 11451 26945 5391809 21237 103983 226399 27076 12780 1808759 12780 1224 1483293 254266 94484 34968 418182 34787 2556 2556 2556 68 373838 297345 76493 19493 36576 7647 188122 2821440 68699 10000

2002 100194 108967 38048 24954 8854 172200 5641752 25520 556 85192 245916 21420 11019 1761721 11019 1038 1435941 227387 75748 37005 377340 37005 1799 1799 1799 36 353114 278178 74936 35151 54234 14339 151961 2856539 47807 94000

2003 119712 106330 42234 54024 29031 169828 4635132 28491 621 88657 256534 18894 6338 1632024 6338 868 1518179 205103 72620 48441 526874 48441 1171 1171 1171 64 208364 300591 92227 43386 54524 15240 135989 2738600 38790

2004 91855 99593 37389 51359 22356 145676 4212559 27197 1714 53808 181259 16183 6154 1577387 6154 788 1736565 222903 91055 50850 446104 50850 864 864 38 412251 321954 90297 42008 53524 14653 108350 2694854 24909

2005 67036 88991 26914 58791 22522 100106 3814715 21936 2632 30359 156954 13615 5569 1425997 5569 588 1614143 267132 92957 46342 581871 46342 12125 1369 1369 45 393288 316898 76390 34912 61092 9834 84473 2728481 19496

2006 89109 94460 33010 102590 45686 116260 3995227 35383 2097 20468 113165 8093 95676 10289 5294 1388267 5294 697 1536399 223464 88817 10756 5121 35405 378535 35405 18171 2051 2051 30 403892 328555 75337 30067 40625 8055 74766 2842429 22637 130000

2007 59848 135731 22081 46989 20437 133699 3958190 29304 1192 20364 159002 6371 113694 11087 5456 1565033 5456 829 1458055 239956 82979 7643 3976 36235 403415 36235 4839 1 2227 2227 35 150126 311447 65404 20215 38214 5471 59601 3634060 16389 78294

2008 58887 130995 20347 51036 21777 135467 4316976 16650 780 19347 168027 4965 143368 14382 7390 1562148 7390 873 1444654 240686 81657 5955 2795 23655 278652 23655 2 1052 1052 29 102140 276639 40535 24279 30267 3473 1639 292 51668 1297365 11355 72087

2009 83777 96886 24999 94788 39596 14598 4637168 9287 22800 173459 5508 84511 9166 7010 1565982 7010 584 1355668 128335 62845 25150 14913 19316 352006 19316 1345 1345 36 84078 231221 33002 0 0 22271 24813 3615 2065 574 49186 2829516 16130 44647

2010 47910 90175 14277 103035 35079 7855 7115784 4990 23047 150512 4524 127790 16276 6650 1619074 6650 831 1254181 198742 75985 20820 17971 18560 301031 18560 1772 1772 1772 56 95006 212329 35373 17300 4331 16831 29180 4013 10246 4156 54297 2760119 17515 7017

2011 51611 86526 13792 130186 43631 4498 9189270 3367 17904 213578 6226 77843 11609 5306 1600439 5306 1142 1023546 184466 70603 27391 13457 9552 327060 9552 0 0 838 838 838 64 80859 182847 23202 17457 3455 5764 19183 2077 12529 2743 45588 2791917 16612 491373

2012 45553 80212 10124 108974 30352 2718 6918657 2603 46819 223934 13232 145425 32970 4725 1566872 4725 924 643214 156495 67202 228857 82993 7133 332063 7133 0 0 555 555 555 47 57296 202620 21904 13987 2479 36708 16981 733 16292 2702 43717 2897730 19638 514725

34963534 32169337 43015913 45271847 64009071 69289106 68255700 70927130 72020886 60123280 82688953 83578030 79369928 77613172 1213388 1181104 982778 895134 889993 909466 1049444 920506 784591 563429 573032 677243 493820 469374 7540977 9312314 8204604 8691031 8847138 5044766 7454992 7253650 8449274 8595623 7542842 7270622 6782758 6999669 3913 33293 24785 20891 16558 10123 5331 3111 1436 757 451 356 311 422 4658138 5122672 6574840 5921344 6033301 6386192 4482500 4247031 3578227 3425385 3058012 4610770 4463996 3760367 333301 2820340 2356139 2383576 2340065 2648381 2377597 2313711 1945826 1868539 1660049 1526109 1245466 888438 48713251 50639060 61159059 63183823 82136126 84288034 83625564 85665139 86780240 74577012 95523339 97663130 92356279 89731442

WORLD MALARIA REPORT 2013 | 239

Annex 6C Reported malaria cases by species, 19902012

WHO Region African Country/area Suspected No. Pf No. Pv No. other Angola Suspected No. Pf No. Pv No. other Benin Suspected No. Pf No. Pv No. other Botswana Suspected No. Pf No. Pv No. other Burkina Faso Suspected No. Pf No. Pv No. other Burundi Suspected No. Pf No. Pv No. other Cabo Verde Suspected No. Pf No. Pv No. other Cameroon Suspected No. Pf No. Pv No. other Central African Republic Suspected No. Pf No. Pv No. other Chad Suspected No. Pf No. Pv No. other Comoros Suspected No. Pf No. Pv No. other Congo Suspected No. Pf No. Pv No. other Cte d'Ivoire Suspected No. Pf No. Pv No. other Democratic Republic of the Congo Suspected No. Pf No. Pv No. other Equatorial Guinea Suspected No. Pf No. Pv No. other Eritrea Suspected No. Pf No. Pv No. other Ethiopia Suspected No. Pf No. Pv No. other Gabon Suspected No. Pf No. Pv No. other Gambia Suspected No. Pf No. Pv No. other Ghana Suspected No. Pf No. Pv No. other Guinea Suspected No. Pf No. Pv No. other Guinea-Bissau Suspected No. Pf No. Pv No. other Kenya Suspected No. Pf No. Pv No. other Liberia Suspected No. Pf No. Pv No. other Algeria 1990 152 243673 92870 10750 496513 92870 69 869048 174436 212554 32428 511916 25552 57450 222538 1438713 21762 81835 1991 229 1143701 118796 14364 448917 568938 80 787796 125038 246410 32391 466895 22598 80247 215414 1372771 17718 64123 1992 106 782988 290868 4995 420186 773539 38 664413 89930 229444 21121 553875 25100 206262 100629 188035 1446947 56073 1993 84 722981 403327 55331 502275 828429 44 478693 82072 234869 12012 15504 421043 17867 305616 70928 1697109 158748 1994 206 667376 546827 29591 472355 831481 21 189066 82057 278225 13860 35957 14827 358469 82245 299824 1672709 607560 6103447 1995 107 156603 579300 17599 501020 932794 127 784321 100962 293564 15707 28008 755812 12530 81183 412609 54849 135909 1928316 600317 197386 4343190 1996 221 623396 80004 582658 974226 77 931311 95259 278048 15509 14000 1109011 198064 129908 478411 74310 266189 2189860 772731 6457 3777022 239998 1997 197 893232 670857 101887 672752 670857 20 787796 99718 343186 9491 983089 509804 57450 325555 2227762 802210 10632 826151 1998 1169028 650025 59696 721480 687301 41 664413 105664 395205 3844 17122 141353 255150 604960 80247 1745214 817949 2113 80718 777754

240 | WORLD MALARIA REPORT 2013

1999 701 1471993 709348 72640 867866 1936584 29 127964 392815 9793 1508042 147062 647919 127899 2895079 807895 197454 122792

2000 27733 261 277 2080348 71555 3252692 6843 144 0 89614 437041 20977 19101 964623 889 0 0 127024 50810 3349528 816539 4800 246316 4216531

2001 26411 247 181 1249767 717290 48281 352587 3345881 7141 107 0 140742 451182 19520 18767 1193288 2199247 1517 138667 8994 722 3014879 233218 157625 132918 53167 481590 3044844 851877 6238 202379 3262931

2002 18803 188 116 1862662 782818 28907 1188870 2626149 8022 76 0 517004 21959 21974 1109751 2640168 1727 121011 5335 743 3617057 262623 164772 157440 62976 620767 3140893 850147 16561 194976 3319399

2003 17059 313 111 3246258 819256 23657 1443184 2243185 6001 68 0 78094 505732 21532 23663 1136810 4386638 2418 6 107599 8998 1348 4129225 291403 171388 166321 58212 540165 3552896 731911 4378 162344 5338008 39383

2004 16686 71 92 2489170 853034 22404 1546644 1749892 9833 45 0 129367 481122 665 695 43918 1275138 4133514 2659 7 65025 3480 639 5904132 396621 178676 200214 70075 395043 3416033 876837 103069 187910 7545541 28328

2005 18392 242 57 2329316 803462 11242 1615695 2334067 7902 68 0 277413 131856 501846 14770 16898 29554 1280914 6334608 2844 110 64056 7506 1567 4727209 374335 158658 235479 70644 329426 3452969 850309 50452 185493 9181224 66043 44875

2006 13869 91 24 2283097 861847 23514 2060867 2265970 8729 80 0 634507 114403 251354 21354 23801 54830 157757 1253408 5008959 2043 3 49703 5750 791 3375994 293326 149020 136916 33458 427598 3511452 834835 41228 148720 8926058 1171175 761095

2007 14745 261 24 2726530 1171522 30906 381 2487633 2079861 8902 18 0 0 604153 119477 518832 24282 24006 53511 163924 103213 0 0 1277670 3720570 1642 7 20948 5842 80428 3006 6508 0 2844963 269514 171710 190749 45186 439798 3123147 457424 0 19060 888643 28646 140205 9610691 694428 80373 0 0

2008 11964 185 10 0 3432424 1147005 41153 914 3790238 1950266 9033 35 0 0 1650749 152260 478987 24015 23742 46426 203869 117291 0 0 1343654 4933845 1196 27 67196 7883 62449 1519 2832 0 3060407 274657 173300 187714 40701 508846 3200147 918105 0 38254 657003 33405 148542 839904 874607 157920 0 0

2009 15635 88 6 0 3726606 1256708 534590 0 0 32460 951 4537600 2588830 21913 65 0 0 1883199 175210 549048 57084 5771 79 132 203160 92855 0 0 1847367 7839435 84532 11603 77946 3358 3244 0 4335001 594751 287114 0 113803 187 23 0 479409 3694671 924095 0 38504 812471 20932 156633 8123689 1035940 212657 0 0

2010 12224 401 4 3 3687574 1432095 12196 1046 5723481 4255301 47 47 0 0 1845691 66484 544243 103670 33791 528 880 446656 1721461 9252959 0 0 78095 39636 96792 9785 3989 57 5420111 732776 390252 0 185105 2157 720 2015 414406 3849536 926447 0 102937 1092554 20936 140143 6071583 898531 2675816 212927 0 0

2011 11974 179 12 0 3501953 1424335 68745 0 0 1141 432 5024697 3298979 26508 36 0 0 1829266 221980 528454 83443 21387 334 557 277263 2588004 9442144 0 0 37267 20601 97479 10263 4932 19 5487972 814547 665813 178822 261967 4154261 593518 0 31238 1189016 5450 197229 11120812 1002805 2480748 577641

2012 15790 860 24 3 3314706 1513212 0 0 308 193 6970700 3808337 17430 36 0 0 1589317 459999 660575 152744 43681 637 1189 117640 2795919 9128398 0 40071 13196 138982 6164 5249 35 5962647 946595 745983 188089 862442 10676731 2971699 0 0 1220574 191421 158095 9335951 1426719 2048883 507967

WORLD MALARIA REPORT 2013 | 241

Annex 6C Reported malaria cases by species, 19902012 (continued)

WHO Region African Country/area Madagascar Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other 1990 3870904 248904 26903 1162824 1116992 1282012 6822 810509 10715736 1933696 662613 22624 1 1659 0 4 1991 282256 42112 808968 909656 1331494 4693 780825 8715736 2340994 581168 16844 3 800 0 3 1992 280562 45687 865976 1219348 1373247 2872 634166 2446659 7681524 2953692 420137 13619 0 643 0 2 1993 4686201 295737 43892 380530 726666 981943 733203 13285 561328 1470662 8777340 3514000 877734 11389 1 757 0 2 1994 4736974 263100 156080 401519 806204 1175004 371550 450071 10289 328488 2191277 7976590 3514000 324188 14070 1 947 0 0 1995 196358 95357 214478 275442 778175 1133926 1391931 51938 628773 8750 1431068 2438040 2742118 761791 12986 0 1065 0 3 1996 6183290 29818 181204 12794 345177 1162824 1149435 1145759 47074 7192 27035 38875 352334 4969273 3215866 1696192 12833 0 2048 0 0 1997 2761269 384907 189571 390601 978855 1148542 1331494 47757 861276 209312 23121 23754 366672 2317840 1131655 1849383 9684 0 592 0 8 1998 2985659 12234 168131 194024 353110 872925 2122663 1279581 46026 948823 249744 26445 4410 368472 2845811 3399630 1719960 9341 0 339 0 21

Malawi

Mali

Mauritania

Mayotte

Mozambique

Namibia

Niger

Nigeria

Rwanda

Sao Tome and Principe

Senegal

Sierra Leone

South Africa

Swaziland

Togo

Uganda

United Republic of Tanzania3

Mainland

Zanzibar

Zambia

Zimbabwe

Region of the Americas

Argentina

Bahamas

242 | WORLD MALARIA REPORT 2013

1999 1141474 4193145 530197 253513 2336640 429571 815895 1965486 906552 37026 1145112 409670 51444 30420 412619 3070800 423967 3385616 1804479 8524 0 222 0 30

2000 1392483 3646212 546634 0 2476608 0 66250 1123377 44959 460881 64624 29374 3552859 53533 17734 53533 17734 3337796 0 7949 1 439 0 22

2001 1386291 3823796 612896 243942 538512 1340142 2253519 1329106 84993 931682 14261 447826 2206 0 26506 35582 1395 0 498826 5624032 369474 18385 324584 53804 18385 3838402 0 6685 0 215 0 4

2002 1598919 2784001 723077 224614 445803 888345 2605381 1519315 94249 960478 15261 507130 3702 0 15649 23456 670 0 583872 7536748 546016 413361 16983 369394 51968 16983 3760335 5043 0 125 0 1

2003 2198297 3358960 809428 318120 468259 681783 2608479 1735774 86546 1414383 28272 524987 3945 0 13459 19425 342 0 490256 9657332 785748 11418731 15705 11379411 53899 15705 4346172 3977 0 122 0 34

2004 1458408 2871098 1969214 224840 610799 760718 53637 3310229 1915990 105341 1195402 23171 355638 2206 0 13399 11320 574 0 516942 10717076 861451 11930393 11936 11898627 50976 11936 4078234 1997066 3018 0 115 0 17 2 0 0

2005 1229385 3688389 962706 223472 339204 817707 74129 3532108 2409080 73050 1346158 38746 233833 3702 0 7755 10374 279 0 437662 9867174 1082224 11466713 7628 11441681 43642 7628 4121356 1709890 3018 1 251 0 9 1 0 0

2006 1087563 4498949 1022592 188025 373 3 2 265595 886531 44612 3982372 2379278 60819 1555310 49366 160666 3945 0 14456 11637 155 0 566450 10168389 850050 10582608 1585 10566201 30676 1585 4731338 1493398 6353 1 211 0 546

2007 736194 4786045 1291853 222476 413 0 1 6155082 172024 2617792 54515 1113 2969950 2318079 49298 1170234 78278 653987 6327 6338 84 0 0 715615 117131 0 0 11978636 1024470 8571839 293 8562200 23511 293 4248295 1272731 6353 2 385 0 6

2008 352870 5185082 1045424 201044 328 4 7 4831491 155399 1092 0 0 2760722 60998 1245 2834174 2096061 316242 358122 737414 24830 932819 7796 5881 58 0 0 898112 151960 0 0 11602700 959712 7652661 67 7643050 229890 77 0 0 3080301 1089322 5157 0 130 0 35 13 0 1

2009 633998 6183816 1633423 174820 399 306 8 20 4310086 102956 505 0 0 2670958 77485 1581 4295686 3186306 698745 119877 584873 19614 1314799 273149 6117 6624 106 0 0 961807 191357 0 195 12086399 1275310 12840249 211 0 12752090 181939 211 0 0 2976395 867135 86 0 86 0

2010 628507 6851108 2171542 244319 2023 355 10 31 4238469 39855 556 0 0 7592288 47806 0 1479 3873463 523513 2708973 638669 58961 2219 14 0 707772 17750 2327928 218473 276669 2181 0 5 2221 87 0 0 1053599 224080 0 7 13208169 1565348 15812 0 12893535 364 0 12819192 200072 364 0 0 4229839 912618 249379 2547 72 27272

2011 774385 5338701 1961070 154003 1214 86 5 0 5471573 74407 335 0 0 3157482 66473 0 2056 4306945 3204542 208858 117279 6363 4 6 598658 14142 933274 25511 382434 326 14 15 2471 130 0 0 893588 237282 0 23 12173358 134726 0 0 10164967 475 0 10160478 455718 475 0 0 4607908 480011 0 0 7872 18 31013

2012 944533 5265474 2171739 169104 1463 66 2 4 4781207 10844 194 0 0 3888044 81707 0 2527 6938519 3095386 422224 126897 10700 1 4 637594 11905 2170759 104533 152561 568 5 7 1401 78 0 0 1240134 260526 0 9 13591932 1413149 0 0 8477435 674 0 8474278 536524 674 0 0 4695400 727174 7027 0 4 0 0

WORLD MALARIA REPORT 2013 | 243

Annex 6C Reported malaria cases by species, 19902012 (continued)

WHO Region Region of the Americas Country/area Suspected No. Pf No. Pv No. other Bolivia (Plurinational State of ) Suspected No. Pf No. Pv No. other Brazil Suspected No. Pf No. Pv No. other Colombia Suspected No. Pf No. Pv No. other Costa Rica Suspected No. Pf No. Pv No. other Dominican Republic Suspected No. Pf No. Pv No. other Ecuador Suspected No. Pf No. Pv No. other El Salvador Suspected No. Pf No. Pv No. other French Guiana, France Suspected No. Pf No. Pv No. other Guatemala Suspected No. Pf No. Pv No. other Guyana Suspected No. Pf No. Pv No. other Haiti Suspected No. Pf No. Pv No. other Honduras Suspected No. Pf No. Pv No. other Jamaica Suspected No. Pf No. Pv No. other Mexico Suspected No. Pf No. Pv No. other Nicaragua Suspected No. Pf No. Pv No. other Panama Suspected No. Pf No. Pv No. other Paraguay Suspected No. Pf No. Pv No. other Peru Suspected No. Pf No. Pv No. other Suriname Suspected No. Pf No. Pv No. other Venezuela (Bolivarian Republic of ) Suspected No. Pf No. Pv No. other Afghanistan Suspected No. Pf No. Pv No. other Belize 1990 17204 40 2987 6 121743 652 19028 0 3294234 252191 308184 21 496087 35490 63855 144 113167 5 1146 0 297599 334 22 0 363080 21871 49799 0 230246 18 9251 0 49192 2607 3292 10 305791 1008 40703 0 135260 12904 9777 0 13743 4806 0 0 418513 659 52436 0 281 1503208 62 44451 0 466558 1568 34217 0 315359 105 276 0 98417 55 2857 0 90040 131 28693 58 18594 1584 21 3 361194 9135 25944 3 735624 1832 315647 0 1991 25281 131 3181 5 125509 1103 17928 0 3283016 265597 348722 112 740938 70868 113173 115 130530 22 3251 0 343491 367 10 0 346465 13868 45532 0 190540 18 5915 0 55242 1745 1663 71 361743 1616 56070 0 141046 23397 18807 0 81763 25511 468811 1731 71621 0 3 1596427 278 26287 0 364786 1702 25951 0 336569 118 997 0 127807 18 2965 0 109654 187 33502 16 18399 1402 33 55 375473 8182 34641 3 768685 4312 293293 0 1992 24135 165 5175 1 125414 2757 21729 0 2955196 267054 342650 156 736498 69274 114690 59 149198 16 6935 0 299549 694 4 0 377321 15970 25119 0 202446 6 4533 0 56925 2796 1151 125 396171 1480 56080 0 159108 23871 15831 0 37957 13457 0 0 471950 1216 69622 0 6 1668729 129 16041 0 381715 2192 24674 0 308359 113 614 0 149523 10 1279 0 123147 793 54129 0 13765 1326 25 53 336571 5004 16365 47 1993 47742 251 8332 0 125721 5375 22100 0 2551704 176379 289656 180 656632 42508 86816 53 140435 8 5025 0 290073 983 4 0 419590 21646 25213 0 172624 4 3883 0 49993 3154 720 100 276343 2094 39774 0 172469 18091 15081 0 10045 853 0 0 372180 448 44065 0 6 1816340 202 15591 0 440891 2492 41445 0 278557 20 461 0 164146 1 435 0 158325 9634 85504 84 26079 5930 84 113 290483 3501 8988 50 431353 2383 121040 0 1994 50740 420 9991 0 128580 4833 29916 0 2671953 197009 367251 146 572924 34070 93108 40 143721 3 4442 0 316182 1664 5 1 301546 10241 19765 0 139587 5 2798 0 48242 3809 415 17 133611 423 21634 0 168127 22503 17153 0 54973 361776 568 52110 0 3 1923775 63 12801 0 374348 1524 40551 0 237992 18 717 0 96885 12 571 0 295824 21203 100801 35 29148 4384 240 80 210890 3677 12617 17 683034 4459 27142 0 1995 37266 475 8938 0 152748 3374 43537 0 2582017 203402 361560 765 667473 62687 124354 41 143408 16 4499 0 380143 1807 1 0 253714 4738 13390 0 169267 6 3356 0 52521 4137 545 29 135095 671 23490 17 291370 29976 29335 0 373364 1124 58322 0 5 1965682 73 7243 0 493399 3844 67536 0 222498 18 712 0 86664 35 862 1 833614 37591 152868 62 38613 6249 256 101 302487 4251 18168 82 602320 4158 182687 0 1996 35113 455 6150 0 161077 4252 59760 0 2159551 135132 318331 1731 461137 37315 98573 35 148161 65 5415 0 436473 1112 2 0 162128 1886 10028 0 164491 4 5884 0 46780 3980 687 57 97586 130 20140 0 262526 18239 15836 0 69853 18877 0 0 305167 874 73613 0 206 2053773 87 6206 0 461989 2733 73536 0 188914 25 451 0 68151 5 632 0 1162230 50009 161375 124 68674 14942 744 258 285326 4098 17714 40 590624 2501 75749 0 1997 26598 126 3887 0 141804 5381 46097 0 1869382 95084 296686 1206 583309 66261 114544 105 155925 45 4667 0 446874 812 4 0 174692 3091 13274 0 166895 5 2714 0 42631 2349 715 131 140113 879 31220 0 229710 20238 11865 0 35132 5870 310815 858 65005 0 110 1950935 67 4979 0 410132 1815 50043 0 193853 179 326 0 83104 1 565 1 1299929 53016 127287 35 94508 9251 1125 245 271989 4064 18272 64 540050 5878 183989 0 1998 27000 222 2392 0 176023 11414 62499 0 2089175 105945 345820 1461 190553 100890 89663 0 103976 15 5133 0 453850 1999 7 0 300752 21448 22248 0 161900 11 1171 0 3462 2658 552 210 1049 35355 0 296596 22799 18401 0 34449 34449 0 0 249105 1067 41912 0 207 1806903 159 24864 0 440312 3193 30716 0 187055 125 914 0 42944 3 2087 1 1942529 84289 162695 79 73481 10193 1699 520 333786 5248 15733 65 13665

Eastern Mediterranean

244 | WORLD MALARIA REPORT 2013

1999 19395 52 1801 0 159618 7557 42480 0 2435451 121228 473437 888 268355 25389 41137 319 96454 15 3983 0 453720 3584 5 0 444606 50158 37462 0 144768 9 1221 0 47974 4567 564 214 192710 1708 45284 0 255228 16144 11139 0 1196 1196 0 0 250411 1264 45520 0 219 1906050 96 13354 0 555560 1812 36635 0 161219 40 896 0 101074 2 9944 0 2027624 67215 94077 0 65087 11685 1371 883 218959 3531 15548 7 696082 9131 153253 0

2000 18559 20 1466 143990 2536 28932 0 2562576 131616 478212 932 478820 51730 92702 0 61261 12 1867 0 427297 1226 7 0 544646 48974 55624 0 279072 9 744 0 48162 3051 657 214 246642 1474 50171 36 209197 12324 11694 0 21190 16897 0 0 175577 1446 33679 0 874 2003569 131 7259 0 509443 1369 22645 0 149702 45 991 0 97026 0 6853 0 1483816 20618 47690 13 63377 10648 1673 811 261866 5491 24829 1 366865 5115 89240

2001 18173 6 1156 0 122933 808 14957 0 2274610 81333 306396 574 747079 100242 130991 0 43053 1 1362 0 411431 1034 4 0 538757 37491 71412 0 111830 2 360 0 44718 3166 657 0 198114 1044 34772 0 211221 12831 14291 0 51067 9837 0 0 174430 938 23211 0 596 3 2 1 1857233 69 4927 0 482919 1194 9304 0 156589 39 889 0 71708 4 2706 0 1417423 17687 61680 11 67369 13217 1229 1549 198000 2774 17224 8

2002 15480 0 1134 0 137509 727 13549 0 2118491 80188 267245 826 686635 88972 115944 0 17738 2 1008 0 391216 1292 4 0 403225 20015 66742 0 115378 0 117 0 44718 2547 954 160 197113 1841 33695 0 175966 10599 11296 0 178616 606 16617 0 725 1852553 19 4605 0 491689 995 6700 0 165796 337 1907 0 99338 1 2777 0 1582385 21174 78000 10 68070 9752 1648 1388 278205 2572 26907 12 84528 330083 0

2003 15480 0 1084 0 158299 793 17319 0 2009414 88174 320378 298 640453 75730 105226 0 9622 14 704 0 349717 1528 1 0 433244 10724 41341 0 102053 2 83 0 32402 3080 759 0 156227 1310 29817 0 185877 12970 14654 3 137522 540 13523 0 394 1565155 44 3775 0 448913 1213 5525 0 166807 627 3873 0 126582 4 1388 0 1485012 19154 66588 13 43241 8782 1047 0 344236 5562 26111 46 44243 316697 0

2004 17358 6 1060 2 163307 695 14215 0 2194780 110422 354366 216 562681 55158 87083 0 9204 5 1284 0 322948 2353 2 0 357633 5891 22839 0 94819 1 111 0 32402 2437 600 0 148729 852 28103 0 151938 12226 16141 446 30440 10802 0 0 144516 834 16300 0 3879 1454575 49 3357 0 492319 1200 5699 0 171179 882 4213 0 97246 1 693 0 1438925 20905 72676 0 56975 6738 915 726 420165 4620 41972 63 280301 12789 229233 0

2005 25119 32 1517 0 202021 1080 19062 0 2660539 155169 450687 211 493562 43472 78157 0 12767 3 3538 0 397108 3829 8 0 358361 2212 14836 0 102479 2 65 0 32402 1777 1637 71 178726 1062 38641 48 210429 16438 21255 1291 3541506 21778 0 0 155976 998 14942 0 2470 1559076 22 2945 0 516313 1114 5498 0 208582 766 2901 0 85942 0 376 0 1438925 15058 72611 59855 6931 1611 589 420165 6026 38985 38 548503 5917 110527 0

2006 25755 10 834 0 220616 1785 17210 0 2959489 145858 403383 228 451240 46147 73949 0 24498 32 2667 0 446839 3519 6 0 318132 1596 8267 0 113754 1 48 0 32402 1847 2227 27 168958 804 30289 0 202688 9818 10560 686 87951 32739 0 0 127436 767 11180 0 6821 1345915 16 2498 0 476144 336 2784 0 212254 62 1601 0 111361 2 821 0 1438925 8437 56488 45722 2331 733 225 479708 6928 30111 23 789186 6216 79913 0

2007 22134 0 845 0 181816 1622 12988 0 2986381 93591 364912 149 589755 54509 70753 0 22641 11 1212 0 435649 2708 3 0 352426 1158 7306 0 95857 2 38 0 32402 845 1804 23 132410 196 15182 0 178005 4677 6712 267 142518 29824 1 0 130255 813 9700 0 199 1430717 4 2357 0 537637 106 1250 0 204193 48 1233 0 92339 2 1337 0 1438925 7766 43031 33992 547 509 14 396338 8077 33621 51 869144 6283 85919 0

2008 25550 0 540 0 169826 836 8912 0 2726433 49358 266300 88 493135 22392 56838 0 17304 0 966 0 381010 1839 1 0 387558 396 4495 0 97872 1 32 0 11994 406 925 10 175678 50 7148 0 137247 5741 5927 147 168950 36768 6 0 119484 610 7758 0 30732 21 1 1246780 0 2357 0 543173 61 701 0 200574 4 740 0 96313 7 333 0 861290 4768 33895 29911 838 639 17 414137 5540 26437 60 935043 4355 77219 0

2009 26051 1 255 0 134595 574 8660 0 2711062 50933 258271 112 436366 21441 57111 0 4829 1 261 0 353336 1643 0 0 451732 551 3569 0 83031 1 19 0 20065 424 1003 6 156652 56 7024 0 169309 7542 6029 102 270438 49535 0 0 108522 1382 7931 0 34149 17 4 1 1240087 1 2702 0 553717 93 517 0 158481 3 775 0 64660 10 81 0 36886 4044 32976 0 34717 929 895 18 370258 8776 27002 50 847666 4026 60854 0

2010 27366 0 149 0 140857 808 11444 0 2711432 51048 283435 183 521342 34334 83255 48 15599 2 112 0 495637 2480 2 0 488830 258 1630 0 115256 2 22 0 14373 604 476 5 237075 35 7163 0 212863 14401 8402 132 270427 84153 0 0 152243 985 8700 0 10763 1192081 0 1226 0 554414 154 538 0 141038 20 398 0 62178 5 22 0 744650 2374 29168 3 17074 721 817 36 12385 32710 60 847589 6142 63255 0

2011 22996 1 78 0 150662 231 5877 0 2477821 35273 231368 143 418032 15404 44701 16 10690 4 13 0 477555 1614 2 0 460785 296 937 0 100883 3 12 0 14429 376 339 5 195080 67 6707 0 201693 20309 9066 96 180227 32969 0 0 155785 605 7010 0 5042 1035424 0 1124 0 535925 150 775 0 116588 1 353 0 48611 7 3 0 702952 3018 21984 3 15270 331 382 17 382303 11167 34651 6 936252 5581 71968 0

2012 20789 1 36 0 132904 348 5993 0 2349341 35379 203018 105 416767 15721 37099 9 7485 0 5 2 506583 950 2 0 459157 80 478 0 124885 3 16 0 13638 264 257 2 186645 68 5278 0 196622 20293 11206 74 161236 25423 0 0 141165 581 5853 0 3687 1025659 0 833 0 552722 236 999 0 107711 1 843 0 31499 11 4 0 759285 3399 28030 7 17464 126 167 2 410663 13302 39478 23 847933 1231 53609 0

WORLD MALARIA REPORT 2013 | 245

Annex 6C Reported malaria cases by species, 19902012 (continued)

WHO Region Eastern Mediterranean Country/area Djibouti Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other Suspected No. Pf No. Pv No. other 1990 11463 3072 165 0 69 6 0 36313 40600 4 30907 1777 1 2608398 43106 36514 0 14943 420 303 80986 11170 178 36 0 0 0 0 24 0 24 0 1 0 1 0 216 136 175 8680 1 0 28 0 53875 34061 19814 1991 26761 7165 170 0 19 5 0 45035 50253 8 6 1758 0 17817 1426 4 271586 26860 39658 0 8575 1302 80 24 26 3 103700 12345 318 52 0 0 0 0 113 0 113 0 2 0 1 0 169 109 294 12218 17 0 12 3 63578 30282 33293 1992 28636 7296 172 0 10 6 0 26542 49310 8 7 5745 0 13958 845 0 2668997 53310 45591 0 17340 2182 101 15 438 2 126580 0 0 0 0 27 0 27 0 1 0 2 0 160 404 18676 11 0 25 9 115660 51775 63885 1993 13 4 0 25900 37917 18 16149 694 0 2615771 40821 51707 0 6467 2880 52 103 172403 0 0 0 0 23 0 23 0 0 0 0 0 209 85 619 47210 3 0 36 6 125402 54973 70429 1994 25366 6048 92 0 475 20 0 19451 21 98222 0 6543 669 0 2796528 49759 7814 97436 145 160687 34735 196 0 196 0 667 0 667 0 1 0 6 0 335 86 2411 84345 9 0 21 2 166564 81015 85549 1995 1282 513 6 16537 502 0 502 0 2840 0 2840 0 1 0 3 0 425 69 6103 82096 10 0 27 0 152729 75860 76869 1996 21 12121 754 500 11 2711179 46645 84496 27 347 0 347 0 13135 0 13135 0 7 0 26 0 611 80 16561 60884 14 0 51 2 100864 54278 46505 1997 9 2 0 8698 12 9582 0 552 469 5 2914056 25255 68154 19 8533872 553937 841 0 841 0 9911 0 9911 0 1 0 13 1 831 97 29794 35456 14 0 52 0 68594 42342 26252 1998 4523 28416 12 523 551 19 3187814 24910 38661 1156 0 1156 0 5175 0 5175 0 16 0 11 0 1081 19351 36842 137 0 74 437928 42222 17801

Egypt2

Iran (Islamic Republic of )

Iraq

Oman

Pakistan

Saudi Arabia

Somalia

South Sudan*

Sudan

Syrian Arab Republic2

Yemen

European

Armenia1

Azerbaijan

Georgia

Kyrgyzstan

Russian Federation

Tajikistan

Turkey

Turkmenistan1

Uzbekistan

South-East Asia

Bangladesh

246 | WORLD MALARIA REPORT 2013

1999 3247 456 416 29 3440986 30347 616 4 616 0 2315 3 2315 0 51 0 5 0 792 63 13493 20963 49 0 85 3 386153 44363 19360

2000 17 0 0 2546 316 366 12 356 1 140 0 527688 0 1526 0 173 0 245 0 70500 0 12 0 795 60 233785 831 18233 0 1597290 7 11424 1 50105 24 0 735164 1 125 0 742539 39475 16124

2001 9 2158 17145 0 283 336 16 7024978 41771 83504 0 2360 678 28 174 0 79 0 536260 1 1056 0 3574 0 438 0 72020 0 28 0 898 248565 826 10561 0 1550521 11 10799 2 50075 8 0 691500 0 77 0 516052 39274 14942

2002 8 2 0 2382 13176 0 266 315 9 7530636 32591 75046 0 1999 567 42 102540 15732 0 0 667794 73667 1659 122 165 0 52 0 507252 0 506 0 6145 1 473 0 69807 1 2742 0 642 48 244632 509 5651 0 1320010 12 10209 3 59834 0 18 0 735164 1 72 1 527577 46418 15851

2003 44 1 0 4475 19087 0 1 346 0 299 428 13 8662496 39944 85176 1234 462 28 28356 7571 0 0 612693 47782 1474 126 4 25 0 536822 0 482 0 5457 2 314 0 144070 0 468 0 533 51 296123 252 5176 0 1187814 12 9209 1 72643 0 7 0 812543 0 74 0 679981 41356 13298

2004 39 4 0 1380 12441 0 1 154 0 158 449 8 6074739 32761 93385 538 55423 11436 0 0 611552 47306 1297 7 220 2 45 0 545145 0 386 0 3365 1 255 0 79895 0 93 0 382 43 272743 151 3437 0 1158673 13 5289 0 71377 0 3 0 893187 0 66 0 512876 46402 12492

2005 3969 413 0 0 23 0 0 2219 16747 0 0 47 0 153 385 6 8671271 42056 85748 0 63770 12516 0 0 17 629380 42627 1442 27 209 0 7 0 515144 0 242 0 5169 0 155 0 114316 0 226 0 205 31 216197 81 2228 0 1042509 32 2052 0 56982 0 1 0 917843 0 102 0 462322 37679 10442

2006 1796 0 0 27 2 0 1199 14710 0 0 24 0 100 341 2 8680304 37837 86999 984 280 12 16430 0 0 27 962017 53887 1019 10 230 0 0 0 498697 0 143 0 4400 1 59 0 74729 1 318 0 143 41 175894 28 1316 0 934839 29 767 0 58673 0 1 0 924534 3 73 0 341293 24828 8029

2007 7945 210 0 0 28 2 0 1266 14322 0 0 3 0 93 602 2 9330723 39856 88699 15 2349 515 0 16058 617 0 4597254 68000 35 740940 64991 2339 0 658 1 0 0 465033 1 109 0 3400 0 24 1 62444 0 96 0 35784 42 76 4 159232 7 628 0 775502 29 329 0 65666 0 0 0 858968 2 87 0 270137 44910 13063

2008 6305 119 0 0 76 4 0 938 10337 0 1 5 0 94 870 1 8330040 24550 79868 36 833 658 0 120060 36167 738 0 201036 4555054 46 900735 42702 745 4 30761 1 0 0 408780 1 72 0 4398 1 7 0 40833 0 18 0 28340 47 46 3 158068 2 316 0 616570 23 191 1 75524 0 1 0 883807 0 27 0 526701 34920 14409

2009 81 13 0 485 5485 0 0 1 0 160 718 2 7973246 37079 95604 0 1649 672 12 106341 24698 504 0 4440882 25751 38 1 0 899320 52836 589 3 31467 0 0 0 451436 0 80 0 4120 5 1 1 33983 0 4 0 27382 62 40 5 165266 1 164 0 606875 16 65 3 94237 0 0 0 916839 1 3 0 569767 18242 6853

2010 1010 0 0 82 3 0 339 2610 0 2 4 0 140 1039 3 8601835 73857 143136 0 883 1023 24 220698 5629 0 0 2398239 19151 19 0 3 835018 77271 966 2 31026 1 0 0 456652 2 50 0 2368 0 0 0 30190 0 6 0 33024 60 34 5 173523 1 111 0 507841 49 28 0 81784 0 0 0 921364 0 5 0 496616 16658 3824 0

2011 356 107 9 0 463 2668 0 3 7 0 101 1422 0 8418570 73925 205879 0 1045 1719 19 99403 112024 25109 37 9 0 804940 59689 478 33 0 449168 2 6 0 2032 3 3 0 27850 1 4 0 28311 39 40 6 173367 5 73 0 421295 97 30 1 0 886243 1 0 0 390102 17543 2579 0

2012 1410 25 0 0 179 26 0 144 1418 0 0 8 0 8902947 70006 215950 0 1279 2088 35 2348433 19136 40 1 1 891394 109504 398 4 0 497040 1 3 0 1046 3 2 0 18268 1 2 0 0 209239 2 31 0 337830 131 243 1 0 805761 1 0 0 309179 3614 361 0

WORLD MALARIA REPORT 2013 | 247

Annex 6C Reported malaria cases by species, 19902012 (continued)

WHO Region South-East Asia Country/area Suspected No. Pf No. Pv No. other Suspected Democratic People's Republic of Korea No. Pf No. Pv No. other India Suspected No. Pf No. Pv No. other Indonesia Suspected No. Pf No. Pv No. other Myanmar Suspected No. Pf No. Pv No. other Nepal Suspected No. Pf No. Pv No. other Sri Lanka Suspected No. Pf No. Pv No. other Thailand Suspected No. Pf No. Pv No. other Timor-Leste Suspected No. Pf No. Pv No. other Cambodia Suspected No. Pf No. Pv No. other China Suspected No. Pf No. Pv No. other Lao People's Democratic Republic Suspected No. Pf No. Pv No. other Malaysia Suspected No. Pf No. Pv No. other Papua New Guinea Suspected No. Pf No. Pv No. other Philippines Suspected No. Pf No. Pv No. other Republic of Korea Suspected No. Pf No. Pv No. other Solomon Islands Suspected No. Pf No. Pv No. other Vanuatu Suspected No. Pf No. Pv No. other Bhutan 1990 9497 4231 5266 0 2018783 752118 1266665 1484496 8544 166505 989042 112928 20112 847491 1853 21003 287384 57736 223245 273880 173265 99369 123796 117359 22044 50500 104900 86200 0 116500 28805 1991 22126 13138 8988 0 2117460 918488 1198972 1631710 7544 132808 1959860 107079 19877 781543 5066 24069 400263 76541 323722 198383 122730 87136 102930 101600 41048 39189 86500 86400 0 141400 19466 1992 28900 14092 14808 0 2125826 876246 1249580 1431284 6888 103116 1702210 106695 19006 725068 2954 20280 399349 82655 316694 168370 97389 70981 91000 74000 38500 36853 86500 95778 0 153359 13330 1993 28116 12943 15173 0 2207431 852763 1354668 1337373 11433 134906 1483408 100570 16154 596689 1609 14771 363197 77970 285227 115220 68270 46950 99200 59000 41787 39890 66797 64944 1 126123 10469 1994 39852 16474 22427 0 2511453 990508 1520945 1698040 9646 136730 1323458 95791 15832 430801 1200 8684 273502 47638 225864 102119 57073 45046 85012 62000 52601 58958 65000 61959 20 131687 3771 1995 23188 7540 15655 0 2988231 1173599 1814632 1510425 2967 140396 1156351 83397 17051 338189 844 8868 142294 119056 23238 82743 45268 37475 76923 47118 52021 59208 99000 56852 107 118521 8318 1996 15696 6026 9670 0 3035588 1179561 1856027 1747287 6178 173700 1054920 78910 17293 204355 951 8069 184319 44957 139362 87622 46550 41072 74883 33382 77894 51921 71013 40545 396 84795 5654 1997 9029 3614 5415 0 2660057 1007366 1652691 1325633 7490 123594 883050 72753 15853 160253 252 6307 218550 54694 163856 97540 48318 49222 88029 26800 72190 26649 38105 42005 1724 68125 6099 1998 7693 3985 3708 2100 2222748 1030159 1192589 1708020 10866 169104 893313 85658 19052 175879 776 8119 211691 42396 169295 131055 69063 61992 10332 58874 27090 39031 13491 20900 50709 3992 72808 6181

Western Pacic

Suspected cases are calculated by adding examined cases to presumed cases Presumed cases are calculated by subtracting conrmed cases from presumed and conrmed cases 1 Armenia, Morocco and Turkmenistan are certied malaria-free-countries, but are included in this listing for historical purposes 2 There is no local transmission 3 Where national totals for the United Republic of Tanzania are unavailable, refer to the sum of Mainland and Zanzibar * In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

248 | WORLD MALARIA REPORT 2013

1999 12237 6531 5706 15362 2284713 1141359 1143354 1243213 21003 116999 851297 98261 20419 124 132044 1089 8610 264549 63878 200671 125379 64433 60946 64679 26797 28050 11106 18564 37061 3621 63169 5152

2000 152890 2738 3197 204428 86790375 1047218 984572 2939329 89289 156323 843087 95499 21802 252 140768 560 7056 1781372 59650 150389 4403739 43717 37975 47 15212 281444 46150 4505 0 496070 38271 1689 1832802 6000 5953 1751883 63591 14721 444668 25912 4183 601612 46703 21322 58679 3226 2972

2001 131948 2915 2805 300000 0 115615 90389019 1005236 1080248 4113458 85596 190608 954155 130029 35783 941 266917 428 6216 1353386 10600 55922 4100778 29061 34467 40 83049 202179 37105 4408 5397517 3732 17295 303306 25851 1204 1808759 5643 6315 1643075 74117 18113 418363 18006 2556 594690 50806 25649 48422 3402 4236

2002 149392 3207 3015 354503 0 98852 91617725 897446 943781 3582566 98430 190048 1016514 133187 35030 864 304200 2165 10621 1390850 4848 36563 3819773 20389 24166 40 120344 26651 11148 187213 33010 4386 5788432 5753 19581 309688 20696 712 1761721 5486 4921 1587580 58403 14187 377340 22831 1799 556356 50090 24822 75046 7016 7210

2003 122492 1518 2126 76104 0 16538 99136143 857101 1012302 3555381 81591 161180 1020477 138178 35151 867 383322 1195 8200 1192259 1273 9237 3256939 19024 18331 32 83785 33411 15392 208801 36338 5179 4776469 3497 24852 326297 18307 574 1632024 2756 3127 1650662 54653 14055 526874 32948 1171 416728 64910 27399 82670 8406 6582

2004

2005

2006

2007 102892 288 414 0 7985 0 4795 0 94855000 741076 767851 2556631 159179 1159516 148010 53351 433 265997 1295 3870 1047104 7 191 2041733 16557 16495 16 215402 34174 12544 0 200050 16518 4987 4062585 1613 27550 141 275602 6171 193 7 1565033 1778 2862 615 1618699 60168 16239 2787 408254 8789 3622 17 2227 2227 396169 48612 16653 139 52958 2424 2987 0

2008

2009

2010

2011

2012

109784 120304 132158 966 853 772 1580 871 963 33803 11507 25966 0 0 0 15827 6728 6913 97111526 104120792 106606703 890152 805077 840360 1025211 1011492 944769 3857211 2206129 2219308 98729 127594 160147 145868 147543 177006 883399 787691 820290 114523 124644 149399 34045 37014 50667 501 638 453 293836 361936 327981 743 1181 1358 3892 5691 3932 1198181 974672 1076121 549 134 27 3171 1506 564 3012710 2524788 2280070 13371 14670 14124 13319 14921 15991 29 59 35 242957 185367 223002 39164 43093 37896 16158 15523 13477 183062 165382 207463 31129 17482 24779 5709 9004 7551 4331038 3892885 4076104 3879 3588 2808 23138 18187 32345 218884 173698 210927 15648 13106 18058 491 473 316 1577387 1425997 1388267 2496 2222 1790 3167 2729 2774 1868413 1788318 1676681 63053 62926 56917 18730 22833 22744 446104 593996 396706 29018 20033 24515 6482 8839 864 1369 2051 643908 633796 657110 64449 54001 54441 25927 22515 20971 80879 86170 62637 6999 3817 3522 6350 4453 4405

47389 62790 54760 44494 42512 136 559 140 87 33 148 413 261 92 47 0 0 0 0 0 24299 34818 25147 26513 39238 0 0 0 0 0 16989 14845 13520 16760 21850 0 0 0 0 0 95734579 112496076 119279429 119470044 122159270 775523 839877 830779 662748 524370 750687 723697 765622 645652 534129 2185836 2733407 3089222 3174612 3534331 127813 95557 220077 200662 199977 125150 93801 221176 187989 187583 0 240 2547 2261 981 1230444 1136064 1277568 1210465 1423966 167562 121636 70941 59604 46695 52256 40167 29944 28966 25920 288 319 346 162 103 302774 270798 213353 188702 243432 792 575 550 219 504 3096 2760 2349 1631 1155 0 0 0 1047104 909632 1001107 985060 948250 46 21 18 12 41 623 529 702 158 45 1 2 1931768 1884820 1777977 1450885 1130757 12108 9486 9401 5710 11553 13886 13616 13401 8608 17506 10 23 20 13 3172 215338 198867 266384 225772 182854 34406 29252 28350 14261 1962 11295 12160 11432 3758 2288 0 0 0 0 0 198794 210856 386420 433424 194263 15095 17442 8213 7054 4639 4625 6362 4794 5155 4451 0 0 0 4435793 4642479 7118649 9190401 6918770 1222 948 1269 1370 1419 15323 8214 3675 1907 1080 105 125 20 50 60 311395 266096 280549 291490 369976 4697 5328 4393 5770 11410 247 176 122 442 1715 21 0 1 14 1 1562148 1565982 1619074 1600439 1566872 2268 1885 1681 973 894 3820 3379 3812 2422 1461 1011 1502 984 1758 2306 1606843 1431395 1379787 1151343 878371 60000 48681 56735 59153 58747 16806 11472 13171 9654 7108 1444 1024 1990 632 609 278652 352006 301031 327060 332063 11807 13933 11824 6877 4774 4806 4951 2885 2380 2189 197 262 175 127 57 1052 1345 1772 838 555 11 26 51 56 54 1052 1319 1721 782 501 0 0 0 338244 282297 284931 254506 249520 29492 19580 22892 14454 14053 11173 8544 12281 8665 7787 84 0 52420 44960 48088 32656 66546 1579 1802 1545 770 206 1850 1632 2265 1224 499 0 4 10 2 0

WORLD MALARIA REPORT 2013 | 249

Annex 6D Reported malaria deaths, 19902012

WHO Region African Country/area Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Liberia Madagascar Malawi Mali Mauritania Mayotte Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Swaziland Togo Uganda United Republic of Tanzania3 Mainland Zanzibar Zambia Zimbabwe Argentina Bahamas Belize Bolivia (Plurinational State of ) Brazil Colombia Costa Rica Dominican Republic Ecuador El Salvador French Guiana, France Guatemala Guyana Haiti Honduras Jamaica Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela (Bolivarian Republic of ) Afghanistan Djibouti Egypt2 Iran (Islamic Republic of ) Iraq Oman Pakistan Saudi Arabia Somalia South Sudan* Sudan Syrian Arab Republic2 1990 57649 2284 35 4863 0 0 0 7 927 176 0 2 0 0 8 180 0 39 28 1 1 1 53 1434 1991 1947 19 4998 0 0 2 743 181 0 0 0 0 2 127 4 101 0 47 1 0 4 57 1898 1992 1068 14 3315 0 0 557 138 0 7 0 2 14 0 38 1 0 48 1935 1993 710 45 4689 0 485 100 0 5 5 0 0 38 0 10 2 2404 1994 1686 12 5775 0 0 29 436 75 0 11 67 150 0 10 0 39 20 22 0 1 2464 1995 250 3268 44 0 355 62 0 14 0 16 0 39 25 47 2 2759 1996 469 4773 163 0 14 224 16 2 5 61 0 1 8 0 46 24 44 8 2 1944 1997 141 35982 547 1018 4603 1205 104 1192 2 0 1 21 151 16 5 18 4 0 32 37 0 17 0 59 9 56 22 6 1825 1998 2 682 23 2624 374 1337 404 2798 13 665 279 896 404 1823 6197 2736 154 1029 198 109 475 1248 2 0 0 27 170 33 0 14 16 0 2 9 34 25 0 0 0 21 0 0 52 14 62 28 1958

Region of the Americas

Eastern Mediterranean

250 | WORLD MALARIA REPORT 2013

1999 6 25572 544 49 2808 484 50 974 169 2826 13 1545 640 4747 583 525 1189 531 2165 4123 1881 1235 406 149 766 8580 1139 0 0 0 15 203 12 0 13 16 5 0 56 0 0 0 11 0 1 49 18 24 3 2622

2000 2 9510 691 439 712 3856 2016 6108 626 48767 591 748 1244 254 1275 424 379 379 0 0 0 11 243 41 0 6 0 0 0 0 16 0 0 0 4 1 0 20 24 24 4 2162

2001 1 9473 468 29 4233 417 0 535 957 416 133 1681 1693 275 1717 517 635 48286 742 3355 562 1728 2366 4317 4275 248 1515 328 81 62 1394 2066 1228 838 390 9369 0 0 0 0 142 58 0 17 0 0 3 0 30 62 0 0 0 2 1 0 25 23 28 2 0 2252

2002 14434 707 23 4032 483 2 98 2152 86 1607 1141 259 2376 440 780 47697 575 5775 826 1504 2769 4092 3167 321 1226 461 96 46 1661 1256 815 441 374 9021 1844 0 0 0 4 93 40 0 11 0 0 2 0 27 76 0 0 0 8 2 0 12 15 23 2 0 8 2125

2003 38598 560 18 4860 425 4 417 1021 989 79 2138 692 192 2103 586 1137 51842 817 4767 1309 1106 2248 5343 2679 193 1602 157 142 30 1130 30194 15251 14943 308 9178 1044 1 0 1 103 24 0 12 0 0 5 0 41 102 0 0 0 7 4 0 9 18 40 5 0 54 2479

2004 12459 944 19 4205 689 4 859 13 28 13613 24 3327 466 153 1575 528 565 25403 715 3457 1012 1185 1333 6032 2362 169 1524 126 88 28 1183 39406 19859 19547 312 8289 1809 0 0 1 3 100 25 0 16 0 0 1 2 38 23 0 0 0 1 2 0 6 7 35 1 0 79 1814

2005 13768 322 11 5224 776 2 836 668 558 92 15322 49 1086 353 426 2037 490 565 44328 41 699 5070 1285 1325 2060 6494 2581 85 1587 50 63 17 1024 36397 18322 18075 247 7737 1916 0 0 0 0 122 28 0 16 0 0 2 4 32 29 1 0 0 6 1 0 4 1 17 0 1 0 0 52 0 15 1789 2

2006 10220 1226 40 8083 434 8 930 865 837 56 12970 47 1357 238 150 3125 507 40079 877 441 6464 1914 67 571 1150 6586 2486 26 1678 90 87 27 819 41787 20962 20825 137 6484 802 0 0 1 0 105 53 0 10 0 0 5 2 20 32 0 0 0 1 1 0 6 1 11 29 0 1 0 0 9 0 58 1193 2

2007 9812 1290 6 6472 167 2 1811 578 617 20 113 797 14372 42 991 216 424 4622 472 370 310 428 7486 1782 142 5816 181 1358 10289 1772 3 1935 324 37 17 1236 25122 12593 12529 64 6183 401 0 0 0 0 93 19 0 17 0 0 5 3 20 28 2 0 0 0 1 0 2 1 16 25 1 0 3 0 0 24 2 45 1254 1

2008 0 9465 918 12 7834 595 2 7673 456 1018 47 143 1249 17940 4 19 1169 156 403 3889 441 487 345 355 8048 1227 4424 152 2461 8677 566 16 741 871 43 10 2663 24902 12497 12405 92 3781 232 0 0 0 0 67 22 0 11 1 0 2 0 11 17 2 0 0 0 1 0 2 0 9 46 2 3 0 2 0 49 263 1125 1

2009 0 10530 1375 6 7982 1183 2 4943 667 221 116 18156 21168 23 23 1121 197 240 3378 586 369 1706 348 8915 2331 91 3747 68 2159 7522 809 23 574 1734 45 13 1556 33472 16776 16696 80 3862 108 0 0 0 0 85 12 1 14 0 0 1 0 11 6 1 0 0 0 0 0 2 0 11 32 0 2 0 2 0 45 254 1142 1

2010 1 8114 964 8 9024 2677 1 4536 526 886 53 1023 23476 30 27 1581 182 151 3859 735 296 26017 1422 427 8206 3006 211 0 3354 63 3929 4238 670 14 553 8188 83 8 1507 31686 15867 15819 48 4834 255 0 0 0 0 76 23 0 15 0 0 0 18 0 3 0 0 1 1 0 0 1 18 22 0 2 0 0 0 0 6 1053 1023 0

2011 0 6909 1753 8 7001 2233 4 3808 858 1220 19 892 1389 23748 52 12 936 74 440 3259 743 472 713 398 6674 2128 77 0 3086 36 2802 3353 380 19 472 3573 54 8 1314 23605 11806 11799 7 4540 451 0 0 0 69 18 0 10 0 0 2 0 3 3 2 0 1 0 0 0 1 3 40 0 4 0 0 0 4 2 5 406 612 0

2012 0 5736 2261 3 7963 2263 0 3209 1442 1359 17 623 1534 21601 77 30 1621 134 289 2855 979 370 785 1725 552 5516 1894 106 0 2818 4 2825 7734 459 7 649 3611 72 7 1197 15632 7820 7812 8 3705 351 0 0 0 64 20 0 8 0 0 2 0 3 0 1 0 2 0 0 2 0 6 36 0 0 260 0 1321 618 1

WORLD MALARIA REPORT 2013 | 251

Annex 6D Reported malaria deaths, 19902012 (continued)

WHO Region European Country/area Yemen Armenia Azerbaijan Georgia Kyrgyzstan Russian Federation Tajikistan Turkey Turkmenistan1 Uzbekistan Bangladesh Bhutan Democratic People's Republic of Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu Viet Nam African Region of the Americas Eastern Mediterranean European South-East Asia Western Pacic Total 1990 0 0 0 1 0 0 0 50 2 353 5127 14 1287 1020 35 372 43 457 913 0 33 32 3340 67115 1423 1434 1 6833 6245 83051 1991 0 0 0 1 0 0 1 132 36 421 5231 19 1747 1163 457 924 0 46 32 4646 6964 1269 1898 2 7586 7268 24987 1992 0 0 0 4 0 0 0 402 49 422 4739 9 1050 1408 52 438 25 500 864 0 33 26 2632 4397 805 1935 4 6671 5978 19790 1993 0 0 0 1 0 0 1 382 62 354 4219 7 997 1100 19 418 23 448 811 0 40 13 1026 6154 645 2404 2 6021 3898 19124 1994 0 0 0 3 0 0 0 1278 48 1122 4380 0 50 908 1009 43 609 28 281 784 0 49 8 604 7473 837 2487 3 7786 3415 22001 1995 0 0 0 2 0 0 0 1393 39 1151 3744 0 5 856 614 34 620 35 415 643 0 51 12 348 3562 558 2761 2 7188 2772 16843 1996 0 0 0 3 0 0 0 794 25 2803 148 3424 15 26 826 745 30 608 40 514 536 0 30 8 203 10178 445 1954 3 8061 2714 23355 1997 0 0 0 4 7 0 0 0 469 14 879 199 2943 2 61 764 811 46 606 25 390 514 0 27 1 152 49395 428 1853 11 5331 2572 59590 1998 0 0 0 3 0 0 0 0 528 17 666 45 3182 7 115 688 621 24 427 27 651 561 0 33 9 183 30821 481 1986 3 5248 2536 41075

South-East Asia

Western Pacic

Regional summary

Less than 18% of countries reported in Africa during 19901999 Deaths reported before 2000 can be presumed and conrmed or only conrmed depending on the country 1 Armenia, Morocco and Turkmenistan are certied malaria-free-countries, but are included in this listing for historical purposes 2 There is no local malaria transmission 3 Where national totals for the United Republic of Tanzania are unavailable, refer to the sum of Mainland and Zanzibar * In May 2013 South Sudan was reassigned to the Who African Region (WHA resolution 66.21 http://apps.who.int/gb/ebwha/pdf_les/WHA66/A66_R21-en.pdf ). Nonetheless, since most data in this report precede 2013, South Sudan is placed in Eastern Mediterranean Region

252 | WORLD MALARIA REPORT 2013

1999 0 0 0 0 3 0 0 0 552 16 1048 3331 740 891 52 338 21 567 755 0 23 4 190 73053 423 2625 3 5687 2841 84632

2000 0 0 2 0 0 0 484 15 892 833 2556 77 625 608 31 350 35 617 536 0 38 3 142 77642 390 2166 2 5482 2360 88042

2001 0 0 0 0 3 0 0 0 0 470 14 1015 2814 1 52 424 476 27 242 46 562 439 0 55 4 91 103036 391 2254 3 4790 1942 112416

2002 0 0 0 0 2 0 0 0 0 598 11 973 2634 3 30 361 457 42 195 38 647 71 0 61 13 50 110516 313 2135 2 4610 1574 119150

2003 0 0 0 0 4 0 0 0 0 574 14 1006 2476 5 4 204 492 52 187 21 537 162 0 71 14 50 152657 367 2538 4 4283 1586 161435

2004 0 0 0 0 5 0 0 0 0 505 7 949 508 1982 7 1 230 65 382 31 105 35 619 167 0 51 3 34 114045 260 1894 5 4254 1427 121885

2005 0 0 0 0 3 0 0 0 0 501 5 963 88 1707 10 0 161 71 296 48 77 33 725 145 0 38 5 18 137269 263 1859 3 3506 1385 144285

2006 73 0 0 0 0 4 0 0 0 0 508 7 1708 494 1647 42 1 113 68 396 37 21 21 668 124 0 12 1 41 136955 248 1365 4 4588 1321 144481

2007 0 0 0 0 2 0 1 0 1 228 2 0 1311 1261 3 1 97 60 241 18 14 18 559 73 1 15 5 20 102490 207 1355 4 2963 964 107983

2008 0 0 0 0 2 0 3 0 0 154 2 0 1055 669 1087 0 101 33 209 23 11 30 628 56 0 21 4 25 103401 147 1491 5 3101 1007 109152

2009 38 0 0 0 0 1 0 1 0 0 47 4 0 1144 900 972 8 0 70 53 279 10 5 26 604 24 0 53 2 26 130969 144 1516 2 3198 1029 136858

2010 92 0 0 0 0 0 0 0 0 0 37 2 0 1018 432 788 6 0 80 58 151 19 24 13 616 30 1 34 1 21 149433 156 2198 0 2421 910 155118

2011 75 0 0 0 0 0 0 0 36 1 0 754 388 581 2 0 43 16 94 33 17 12 431 12 2 19 1 14 103672 112 1148 0 1821 635 107388

2012 72 0 0 0 0 0 11 1 0 519 252 403 0 0 37 3 45 14 44 12 301 16 0 18 8 102788 108 2308 0 1226 458 106888

WORLD MALARIA REPORT 2013 | 253

m a l a r i a

a t l a s

p r o j e c t

For further information please contact: Global Malaria Programme World Health Organization 20, avenue Appia CH-1211 Geneva 27 Web: www.who.int/malaria Email: infogmp@who.int

ISBN 978 92 4 156469 4