Pan American Health Organization · 1st edition, 2023
Operational guidance for national malaria programmes in the Americas on stratification, microstratification, and focus management to achieve elimination.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2023
- Audience
- National and subnational malaria-programme managers, epidemiologists, entomologists, health-service personnel, and technical partners in malaria-endemic and elimination-certified countries.
- Evidence
- Consensus operational guidance based on WHO Global Technical Strategy 2016–2030, WHO Framework for Malaria Elimination (2017), and WHO Malaria Surveillance Reference Manual (2018); no formal GRADE rating.
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 2023 Pan American Health Organization manual operationalizes WHO’s Global Technical Strategy for Malaria 2016–2030 for the Americas. It shifts malaria programmes from control toward elimination by emphasizing: (1) stratification of entire territories by transmission intensity, receptivity, and vulnerability (four strata from non-receptive to active transmission); (2) a diagnosis–treatment–investigation–response (DTI-R) strategy triggered by every case; (3) microstratification—identifying and characterizing foci or micro-areas at the local level; and (4) microplanning—organizing local networks to achieve diagnosis within 48 hours of symptom onset, treatment on the day of diagnosis, investigation within 3 days, and response (reactive case detection and vector control) within 7 days.
The manual treats elimination as a continuous process of transforming active foci into cleared foci. It prioritizes passive case detection accessible to all communities, with active (proactive and reactive) detection as a complementary intervention. Vector control (long-lasting insecticidal nets and indoor residual spraying) should be proactively planned in all areas with active or residual transmission and in receptive areas at high risk of parasite importation, not merely as a reactive measure. The approach is especially relevant for Plasmodium vivax, which predominates in the Americas and whose hypnozoites, early gametocytes, and relapses complicate elimination.
National programmes are urged to establish standardized operating procedures with defined time frames, develop local focus-management teams, and conduct weekly micro-level data analysis to guide adjustments. Supervision, quality assurance of microscopy and rapid diagnostic tests, supply management, and intrasectoral coordination underpin the local DTI-R model.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Stratify all territory into 4 strata: (1) non-receptive; (2) receptive, no autochthonous cases, no importation risk; (3) receptive, no autochthonous cases, with importation risk; (4) receptive with autochthonous cases (active and residual foci).
- Diagnosis: parasitological confirmation (microscopy or RDT) within 48 hours of symptom onset for every suspected case.
- Treatment: begin on the day of diagnosis; administer primaquine 0.25 mg/kg single dose for <em>P. falciparum</em> to reduce transmission and 3.5 mg/kg total dose (7–14 days) for <em>P. vivax</em> radical cure.
- Case investigation: complete within 3 days of diagnosis; classify as indigenous, introduced, imported, relapse, or recrudescent.
- Reactive case detection (RCD): within 7 days of diagnosis, screen cohabitants, neighbours (radius 200 m urban, 1–2 km rural), and co-workers; repeat weekly for 30 days after case clearance (up to 6 months for <em>P. vivax</em> in low-case settings).
- Vector control: all populations in active and residual foci (stratum 4) and high-risk stratum-3 areas should be protected with long-lasting insecticidal nets or indoor residual spraying (2–3 cycles per year depending on insecticide).
- Microstratification: identify foci or micro-areas (clusters of localities sharing transmission dynamics), characterize gaps in detection, diagnosis, treatment, and response, and formulate a microplan.
- Data analysis: weekly at the focus level; prioritize localities contributing ≥80 % of cases (Pareto principle); adjust operations when weekly cases per investigation team drop below 3.
Generic activities of specific malaria interventions, by stratum (Table 4, abridged)
Table extracted from the guideline
| Component | Stratum 1 (non-receptive) | Stratum 2 (receptive, no risk) | Stratum 3 (receptive, with risk) | Stratum 4 (active/residual foci) |
|---|---|---|---|---|
| Routine vector control | NA | NA | In prioritized localities or based on increased receptivity/vulnerability | High coverage LLIN or IRS for at-risk population |
| Passive detection | Diagnosis in reference units | Diagnosis in reference units | Diagnosis at local levels and transit/migration areas | Diagnosis at local levels per transmission dynamics |
| Proactive detection | NA | NA | Fixed scheduled or specific actions (e.g. monthly) based on vulnerability | Proactive detection in mobile/migrant populations; 1–2 per month |
| Slide reading | < 48 h | < 48 h | < 48 h | < 24 h |
| Treatment | Available in reference units | Available in reference units | Available at local levels and transit areas | Available at all diagnostic points |
| Investigation of cases/foci | Investigate all | Investigate all | Investigate all | Investigate all (if many cases, differentiate local vs. imported at diagnostic point) |
| Reactive case detection | NA | RCD when a case detected | RCD when a case detected | RCD around index case or clusters |
| Vector control response | NA | NA | LLIN/IRS if vectors found | LLIN/IRS in response to case if locality not already covered |
Source: Pan American Health Organization, Manual for Stratifying Malaria Risk and the Elimination of Foci. Reproduced in summary form.
From the guideline
Verbatim
“Every suspected case of malaria should be diagnosed by microscopy or rapid diagnostic tests (RDT) within the first 48 hours from onset of symptoms.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As WHO consultant and former director of Georgia's National Center for Disease Control, I have seen first-hand how the 2016 malaria-free certification can breed complacency. This PAHO manual, though written for the Americas, offers a template for countries like Georgia to systematize prevention of reintroduction. The stratification into four strata clarifies that even malaria-free territories must maintain active surveillance if receptive and vulnerable—exactly Georgia's position with ongoing labour migration to Tajikistan and sporadic <em>Anopheles</em> findings in Kakheti and Kvemo Kartli. The DTI-R time benchmarks (48 h diagnosis, 3-day investigation, 7-day response) should be adopted verbatim in our national elimination plan. One caveat: the manual presumes a vertical malaria-programme structure with dedicated field teams; Georgia relies on integrated primary care and the National Center for Disease Control's rapid-response units, so adapting the microplanning and focus-management roles to our decentralized model will require clear protocols in the 2025 communicable-disease surveillance regulation.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia achieved elimination of indigenous malaria in 2010 and WHO certification of malaria-free status in 2016. The country now operates in a prevention-of-reintroduction paradigm (stratum 3 in this manual’s terminology): receptive areas with no autochthonous transmission but with risk of imported cases from endemic regions, chiefly through labour migration to countries of Central Asia and the South Caucasus (Azerbaijan, which reported cases until 2012, and Tajikistan). The manual’s framework is directly applicable: Georgia must maintain passive surveillance with parasitological confirmation for every fever case with travel history to endemic areas within the past year (or 3 years for P. vivax risk), investigate and classify each case within 3 days, conduct reactive case detection among co-travellers and household contacts, and ensure entomological surveillance at sentinel sites to monitor receptivity. Indoor residual spraying or distribution of long-lasting insecticidal nets is not routinely required in Georgia but should be available as a rapid response if vectors (Anopheles spp.) are detected during focus investigation. Neighbouring Armenia and Azerbaijan, also certified malaria-free (2011 and 2024, respectively), face similar challenges. National programmes must coordinate cross-border notification, maintain laboratory capacity for microscopy and RDT quality assurance, and ensure that primary-care providers remain alert despite years without indigenous transmission—an operational risk highlighted in the manual. Regular training of microscopists, updating of travel-related case definitions, and annual review of receptivity (climatic suitability, vector presence) are essential surveillance activities for preventing reestablishment.
Questions this guideline answers
Quick answers
What is the DTI-R strategy?
Diagnosis–Treatment–Investigation–Response: a cascade of actions triggered by every malaria case. Diagnosis within 48 h of symptom onset (microscopy or RDT), treatment on the day of diagnosis, case investigation and classification within 3 days, and response (reactive case detection ± vector control) within 7 days. It operationalizes 'surveillance as intervention.'
When should reactive case detection be performed?
Within 7 days of diagnosis for every case or cluster. Screen at minimum cohabitants and neighbours (radius 200 m urban, 1–2 km rural) or co-workers. In low-transmission settings (≤3 cases/week per investigation unit), conduct weekly rounds for 30 days after case clearance; extend to 6 months for <em>P. vivax</em> to detect late relapses. In high-transmission settings, one round targeting clusters suffices.
How should <em>Plasmodium vivax</em> be treated to prevent relapses?
Administer primaquine 3.5 mg/kg total dose over 7–14 days for radical cure of liver hypnozoites, after excluding glucose-6-phosphate dehydrogenase (G6PD) deficiency. Supervised treatment is recommended in low-case settings. Relapses can occur 3–18 months (rarely up to 5 years) after primary infection, particularly with tropical strains circulating in South America, complicating case classification and sustaining transmission.
What defines an active malaria focus?
A defined area with indigenous cases detected in the current calendar year and ecological/epidemiological factors necessary for transmission. A single autochthonous case in a receptive area constitutes an active focus. A residual non-active focus had its last indigenous case 1–3 years ago; a cleared focus has had none for ≥3 years.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2023
- Status
- Current
- Published
- 2023-01-01
- Languages
- English (Spanish ISBN 978-92-75-12199-3 print version)
- Scope
- Stratification methodology, microstratification and microplanning, DTI-R implementation, vector control planning, focus management, and monitoring for malaria elimination in the Americas.
- Audience
- National and subnational malaria-programme managers, epidemiologists, entomologists, health-service personnel, and technical partners in malaria-endemic and elimination-certified countries.
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12200-6 (PDF)
- Evidence
- Consensus operational guidance based on WHO Global Technical Strategy 2016–2030, WHO Framework for Malaria Elimination (2017), and WHO Malaria Surveillance Reference Manual (2018); no formal GRADE rating.
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
Pan American Health Organization. Manual for Stratifying Malaria Risk and the Elimination of Foci. Washington, D.C.: PAHO; 2023. Available from: https://doi.org/10.37774/9789275122006GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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