World Health Organization · 1st edition, 2025 · 77 pages
WHO manual for countries maintaining malaria-free status: surveillance, risk stratification and outbreak response strategies.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2025
- Audience
- Programme managers, coordinators, public health policy-makers, and public health staff at national and subnational levels in malaria-free countries
- Evidence
- Expert consensus informed by evidence reviews, country case studies, outbreak analyses, and technical consultations
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO manual provides comprehensive guidance for countries that have eliminated malaria on preventing the re-establishment of local transmission. Re-establishment is defined operationally as three or more indigenous cases of the same species in the same focus for three consecutive years after transmission was interrupted. The guidance introduces the concept of malariogenic potential – the product of receptivity (ecosystem ability to support transmission) and importation risk (likelihood of parasite influx).
The cornerstone strategy is early detection, notification and rapid response to every malaria case through robust surveillance systems. Countries must maintain capacity for diagnosis, treatment, entomological monitoring, and outbreak preparedness even decades after elimination. The manual emphasises risk stratification to tailor interventions, with particular attention to border areas with neighbouring endemic countries where receptivity and importation risk converge.
Over 40 countries are now certified malaria-free, yet the threat of re-establishment persists, particularly in tropical/subtropical regions with competent vectors and increasing population mobility. The guidance stresses that preventing re-establishment requires sustained political commitment, adequate financing, multisectoral collaboration, and integration into primary health care whilst maintaining specialized malaria expertise and functions.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Re-establishment defined as ≥3 indigenous cases of the same Plasmodium species in the same focus for 3 consecutive years after elimination
- Every malaria case requires mandatory real-time notification, epidemiological investigation within 3 days, and case classification (imported, introduced, or indigenous)
- Passive case detection must cover all territories; suspected malaria includes any fever or history of fever in persons who visited endemic areas, plus unexplained anaemia or splenomegaly
- Test positivity rate >20% in receptive areas or >80% even in non-receptive areas suggests overly restrictive testing criteria
- Reactive case detection should be implemented when introduced or indigenous cases detected; may be phased out after 3 years of zero indigenous cases if yield is low
- Maintain national reference laboratory participating in international certification programmes; ensure external quality assessment through on-site supervision, proficiency testing or blinded cross-checking
- Border areas sharing transmission foci with endemic countries require synchronized vector control, continuous surveillance, and formal cross-border collaboration agreements
- Outbreak preparedness plans must maintain emergency stockpiles (diagnostics, antimalarials, insecticides), trained IRS teams, and defined triggers for response mobilization
Information that may be used to assess and monitor receptivity and risk of importation
Table extracted from the guideline
| Domain | Receptivity factors | Importation risk factors |
|---|---|---|
| Entomological | Presence of malaria vectors, species composition, adult density, behaviour; presence of larval habitats | Importation of infective vectors |
| Epidemiological | Historical data (prevalence, incidence, mortality); stability of transmission; number/distribution of local cases before interruption | Imported malaria cases; influx of potentially infected individuals from endemic countries (migrants, labourers, refugees) |
| Geographic/Environmental | Topography; climatic conditions including trends and extreme weather; environmental changes (development projects, land use, irrigation, deforestation) | Communities where residents have relatives in endemic countries; travellers returning from endemic countries |
| Socioeconomic | Housing types, urbanization | Camps, border crossings, seasonal worker movements |
| Health system | Performance factors: withdrawal/degradation of vector control; declining vigilance | Performance factors: inadequate services for at-risk migrants |
Source: World Health Organization, Prevention of re-establishment of malaria transmission: global guidance. Reproduced in summary form.
From the guideline
Verbatim
“Early detection, notification and a rapid response to every malaria case are the cornerstone activities of preventing re-establishment.”
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 someone who has worked on health systems strengthening and migration health across the WHO European Region, I find this manual timely for countries like Georgia that achieved elimination decades ago but face evolving challenges from global connectivity and climate change. The emphasis on maintaining clinical alertness resonates deeply – we have seen in multiple settings how diagnostic delays among primary care physicians unfamiliar with malaria lead to severe outcomes and local transmission. For the South Caucasus, I would stress the border malaria framework and cross-border collaboration mechanisms, particularly given historical transmission patterns in adjacent regions and seasonal labour migration. The realistic caveat is financing: as malaria recedes from memory, securing sustained domestic funding for specialized entomological capacity, emergency stockpiles that may never be used, and regular training becomes politically difficult. Georgia's experience integrating vertical programmes into the universal health coverage framework since 2013 offers a model, but the manual rightly warns that integration without adequate monitoring and ring-fenced technical capacity risks losing the surveillance sensitivity that prevents re-establishment. We must advocate for malaria prevention as essential public health infrastructure, not optional spending.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia, certified malaria-free by WHO with last indigenous case in the 1960s, this guidance reinforces the need to maintain surveillance capacity despite decades without local transmission. Georgia’s geographical position at the crossroads of Europe and Asia, with land borders with endemic neighbours historically (now mostly eliminated in the region), means continued vigilance is essential. The country’s experience as a WHO consultant hub on health and migration issues makes the guidance on managing imported cases and cross-border collaboration particularly relevant. National programmes should assess whether current passive case detection adequately captures febrile travellers returning from endemic regions (particularly from sub-Saharan Africa and South Asia), ensure malaria remains in differential diagnosis training for primary care physicians, maintain laboratory capacity for microscopic diagnosis and G6PD testing, and review stockpiles of artemisinin-based treatments and diagnostics. The manual’s emphasis on integrating malaria functions into broader public health systems while retaining specialist oversight aligns with Georgia’s health system strengthening agenda.
Questions this guideline answers
Quick answers
What is the difference between malaria elimination and preventing re-establishment?
Elimination means interrupting local transmission (zero indigenous cases) in a defined area through deliberate activities. Prevention of re-establishment is the continued effort after elimination to prevent introduced cases (first-generation local transmission from an imported case) and indigenous cases (second-generation transmission) from occurring, ensuring malaria-free status is maintained. It shifts focus from reducing known foci to proactively managing risk across all territories.
How should countries respond to a single imported malaria case?
Response depends on receptivity and context. At minimum: cure the patient, investigate travel history and residence location, classify the case, and monitor. In receptive areas during transmission season, or if diagnosis was delayed: consider activated passive case detection (testing all fevers regardless of travel history), reactive case detection around the patient's residence, entomological investigation, and potentially reactive vector control (IRS or larviciding). Field investigation with site visit is warranted if there is uncertainty about case classification or if multiple imported cases cluster in time and space.
Should routine vector control with ITNs or IRS continue after elimination?
In most malaria-free countries, routine ITN/IRS is unnecessary and should be phased out after elimination, as receptivity typically declines with development and urbanization. However, in focal areas with high malariogenic potential – particularly border regions with ongoing transmission in neighbouring countries, presence of efficient vectors, and high importation risk – maintaining vector control may be crucial. The decision should be based on risk stratification, quality of surveillance systems, occurrence of introduced cases when control is withdrawn, and available resources.
What defines an outbreak in a malaria-free country?
As a general rule, a single introduced or indigenous case should be considered an outbreak requiring thorough investigation. Some countries use two or more epidemiologically-linked cases (within one incubation period and 800 m proximity) as the threshold. WHO's operational definition of re-establishment is ≥3 indigenous cases of the same species in the same focus for 3 consecutive years. Any clustering of febrile illness in receptive areas with previous malaria history should trigger investigation for malaria, as initial epidemic stages may be misdiagnosed.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Drugs A–Z
Conditions A–Z
GMJ News coverage
Quality & accreditation
Other guidelines on this topic
- Monitoring and epidemiological assessment of mass drug administration in the global programme to eliminate lymphatic filariasis: a manual for national elimination programmes, 2nd ed
- Malaria control in emergencies: field manual
- Polio Eradication Strategy 2022–2026: delivering on a promise, extension to 2029
- Malaria surveillance, monitoring and evaluation: a reference manual, 2nd ed.
- Subnational tailoring of malaria strategies and interventions: Reference manual
- Issuer
- World Health Organization
- Type
- Manual
- Edition
- 1st edition, 2025
- Status
- Current
- Published
- 2025-07-09
- Languages
- English
- Scope
- Global: all countries and regions that have eliminated malaria or are nearing elimination, particularly in tropical and subtropical zones
- Audience
- Programme managers, coordinators, public health policy-makers, and public health staff at national and subnational levels in malaria-free countries
- Pages
- 77
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789-24-0-11208-7
- Evidence
- Expert consensus informed by evidence reviews, country case studies, outbreak analyses, and technical consultations
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
Prevention of re-establishment of malaria transmission: global guidance. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.GMJ 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.
Was this article helpful?
