Malaria Exemption Certification Awarded to Cape Verde: Insights for Global fight Against the Disease

“The archipelago of Cape Verde, home to approximately half a million people and nestled off the northwest coast of Africa, has recently obtained the malaria exemption status awarded by the World Health Organization (WHO). Becoming the third African country to achieve malaria eradication , Cape Verde joins Mauritius, which achieved this goal in 1973, and Algeria in 2019, in the exclusive circle of countries exempted according to the WHO. As of February 2024, 44 countries hold this valuable malaria exemption certificate. This achievement marks a significant milestone in the global fight against malaria, offering valuable lessons for other regions facing this devastating disease. (See our analysis of the WHO’s 2023 World Malaria Report )

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Before delving into the specific case of Cape Verde, it might be useful to briefly outline what the WHO malaria exemption certification entails concretely.

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What is the WHO Malaria Exemption Certification?

The certification of malaria elimination is a mandate entrusted to the WHO by its Member States through a resolution of the World Health Assembly in 1960. This process aims to register a country in the official record of nations that have achieved malaria elimination. Generally, the certification procedure is based on meeting two main specific criteria:

• Assessment of the cessation of transmission, taking into account the coverage and quality of surveillance, the results and impact of strategies and interventions, as well as other factors influencing malaria elimination.
• Countries must demonstrate the establishment of an operational system to quickly detect imported cases and respond to them.

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In a bit more detail, here are the challenges and steps countries must take to obtain the WHO malaria exemption certification.

1. Transmission Interruption: The country must demonstrate, through rigorous and credible data, the interruption of indigenous transmission by Anopheles mosquitoes across its territory for at least three consecutive years while being able to prevent a resurgence of transmission.
2. Rigorous Data Collection: It is essential to have rigorous and credible data to prove the absence of transmission, which requires robust surveillance systems and adequate data collection capabilities.
3. Surveillance and Response Capacities: Countries must be able to demonstrate their surveillance, prevention, and response capacities to potential resurgences, requiring significant investments in health systems.
4. Application Submission: The country submits an application to the WHO, including detailed data (evidence) of malaria transmission absence, as well as information on its surveillance, prevention, and response capacities to potential resurgences at the subnational level. It should be noted that the concept of subnational verification introduced by the WHO with the launch of the Malaria Elimination Framework (6) in 2017 is an assessment process conducted by both countries and the WHO to assess the malaria situation within regions or provinces of a given country. It aims to obtain a detailed and specific picture of malaria prevalence within a country, allowing for a more targeted and tailored response to local realities. This also contributes to strengthening accountability and transparency in the management of malaria programs at local and national levels.
5. Independent Evaluation: This evaluation is conducted by the WHO’s Technical Advisory Group on Malaria Elimination and Certification (TAG-MEC) whose experts conduct field visits to assess the quality of the data presented and determine if the specific verification criteria are met, which generally include prevalence thresholds and performance indicators for malaria control interventions. These visits also aim to assess the country’s ability to promptly identify and respond to imported malaria cases.
6. Application Review and Final Decision: If, following this review, the application is considered complete and compliant with certification criteria, the TAG-MEC can then recommend the issuance of the malaria exemption certificate.

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To avoid any confusion in reading the table below (Figure 1), it is important to clarify that the Technical Advisory Group on Malaria Elimination and Certification (TAG-MEC) was established to replace two previous malaria elimination advisory committees, namely the Malaria Elimination Certification Panel (MECP) and the Malaria Elimination Oversight Committee (MEOC). The primary role of the TAG-MEC is to advise the WHO on granting or withdrawing malaria-free certification for a given country.

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For more information on the WHO certification process, please refer to the document titled: Preparation for Malaria Elimination Certification.

Preparation for Malaria Elimination Certification (p. 8)

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Key Factors of Cape Verde’s Success and Lessons for the Global Community

1. Political Commitment: Political leadership in Cape Verde has played an essential role in the fight against malaria. The ongoing commitment of national authorities, combined with political will to mobilize resources and implement effective policies, has been a key driver of success.

Indeed, this success primarily stems from the strategic malaria control plan implemented from 2009 to 2013. It prioritized strengthening diagnosis, administering early and effective treatments, as well as systematically reporting all cases, all subjected to thorough investigations. As highlighted by Dr. Matshidiso Moeti, WHO Regional Director for Africa, “with strong political will, effective policies, community mobilization, and multisectoral collaboration, malaria elimination is an achievable goal.”

1. Importance of Investment and Health System Strengthening: Cape Verde’s success underscores the need for continued investment in research, public health programs, human resources, and medical infrastructure.

1. Rigorous Surveillance and Monitoring: Establishing robust surveillance systems has been crucial. Close monitoring of malaria cases, combined with rapid and targeted interventions, has prevented the resurgence of the disease. To control the influx of imported cases from mainland Africa, international travelers and migrants have benefited from free testing and treatment.

It is worth noting that targeted insecticide spraying has been used successfully twice by the country to eradicate malaria, first in 1967 and then in 1983. (However, subsequent shortcomings in vector control efforts facilitated the disease’s return.) Meticulous collection and analysis of epidemiological data have also provided a strong foundation for public health decision-making, playing a decisive role in obtaining this certification.

1. Awareness and Community Engagement: Awareness campaigns have played a major role in educating and engaging communities in malaria prevention. Informing the public about the correct use of mosquito nets, eliminating mosquito breeding sites, and seeking prompt medical care in case of symptoms have helped break the transmission chain.

1. International Collaboration: Cooperation with international partners, including non-governmental organizations and global health agencies, has strengthened Cape Verde’s capacity to combat malaria. Joint initiatives, such as the distribution of insecticide-treated bed nets and widespread access to antimalarial drugs, have contributed to reducing cases.

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These holistic aspects echo what the TAG-MEC considers as the strengths of an effective malaria control program. Indeed, in the reports of the first (September 13-14, 2022) and second (January 27, 2023) meetings of the TAG-MEC, Dr. Allan Schapira , based on independent evaluation missions conducted in Morocco, Turkmenistan, Paraguay, Algeria, and China, lists among the structural and determining elements of a successful malaria control program the following points:

• A well-structured program with clear roles for each participating institution;
• Effective coordination and collaboration among participating institutions;
• Adequate resources for malaria control activities;
• Motivated and competent personnel for malaria epidemiology and prevention;
• Strong and vigilant general health services;
• A robust surveillance and response system;
• Free diagnosis, treatment, and prevention of malaria for all populations, including migrants and foreigners;
• A good command structure for policy implementation and well-defined monitoring systems.

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Conversely, among the identified weaknesses, Dr. Allan Schapira lists the following points:

• Inadequate health services in remote areas and for underserved populations;
• Weakness of general health services;
• Low vigilance of general health services;
• Unclear articulation of the functions of specialized institutions that are part of the malaria control program;
• Unclear distribution of roles and responsibilities between the relevant specialized institutions, and between specialized institutions and curative general health services;
• Decentralization of vector control policy leading to sub-optimal implementation of vector control interventions, especially when there is a lack of national-level monitoring and supervision;
• Lack of chemoprophylaxis services for travelers.

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Challenges to Maintain Certification

After reaching the summit, Cape Verde must now consolidate its achievements. To do so, the country must constantly overcome many challenges, including:

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1. Maintaining Surveillance: Ensure the continuity of malaria surveillance systems to quickly detect and respond to any imported or residual cases.
2. Managing Imported Cases: Strengthen diagnostic and treatment capacities to effectively manage imported malaria cases, due to travel and international exchanges.
3. Preparedness for Potential Resurgences: Maintain adequate response capacities to prevent and control any potential resurgence of malaria, especially due to environmental changes and population movements.
4. Community Engagement: Actively involve communities in malaria awareness, prevention, and control to ensure continued adherence to disease control measures.
5. Cross-Border Collaboration: Diseases like malaria do not respect borders. Collaboration between countries, international partners, and regional organizations, involving the sharing of best practices, resources, and data, is crucial to prevent any resurgence of the disease.

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By overcoming these challenges, Cape Verde can maintain its malaria-free status and continue to serve as an inspiring example for other countries engaged in the fight against this disease.

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Conclusion

Dr. Xiaohong Li, working with WHO’s Global Malaria Programme, who also drafted the TAG-MEC report acknowledged that the last mile of malaria elimination can be challenging and that countries face common challenges to cross the finish line. But, the certification process, while improvable, must remain rigorous. For the future, as Dr. Li explicitly states, These adjustments are likely to provide significant support to other countries, especially in Africa, in their successful fight against malaria and their quest for certification.

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Ultimately, the main major lesson to be drawn from Cape Verde’s success is that malaria is not invincible. But to achieve this, it is vital for states to prioritize and continue their focus on the importance of investing in resilient and sustainable health systems. In essence, health should not be perceived as a mere expense, but as an essential investment. It is primarily by holistically strengthening its health system that Cape Verde has succeeded in defeating malaria. Other countries should draw inspiration from this approach by investing in robust health infrastructures and enhancing the skills of health professionals.