Frequently asked questions - Certification of Cabo Verde as eliminating malaria

1. The elimination of malaria reduces a significant contributor to disease morbidity and mortality, further supporting the enhancement in productivity of the population's workforce and relieving pressure on the health system.
2. Eliminating malaria favourably impacts travel advisories for travellers from non-malaria endemicregions, thus potentially boosting the tourism sectors.
3. The attainment of malaria elimination certification is a recognition of a significant public health achievement which often requires continued efforts of several generations to achieve. It is also a recognition of the systems in place which can prevent re-establishment; this also requires sustained attentiveness of the health workforce to the risk of malaria, especially among travellers from malaria-endemic regions and robust epidemic preparedness and response mechanisms relevant to other vector-borne diseases.
4. A post-certification plan provides a viable pathway to enhance multisectoral collaboration and participation in disease control beyond malaria.
5. 
   

• WHO certification of malaria elimination is the official recognition of eliminating all four human malaria parasite species (P. vivax, P. falciparum, P. malariae and P. ovale) in a country. The malaria elimination certification process is a voluntary process requested by eligible member states.

• Following an official request received from the country. WHO certification of malaria elimination requires proof that local malaria transmission by Anopheles mosquitoes has been fully interrupted, resulting in zero incidence of indigenous cases for at least the past three consecutive years, and that an adequate surveillance and response system for preventing re-establishment of indigenous transmission is fully functional throughout the territory of the country.
• After reporting zero indigenous cases for at least the past three consecutive years, the country can submit an official certification request. The country develops a national elimination report to detail the evidence of the claims for malaria elimination and the programme's adequacy in preventing the re-establishment of transmission. The report is submitted to WHO and reviewed by the members of the Technical Advisory Group on Malaria Elimination and Certification (TAG-MEC). A subset of TAG-MEC visits the country to verify the report's findings and develop their evaluation report based on their country visit. The full TAG-MEC meets to discuss the evaluation report and agree on whether certification should be considered or postponed.
• The WHO Malaria Policy Advisory Group (MPAG) ensures the certification process follows the standard steps as published by the WHO. 
• The Director General of the World Health Organization makes the final decision on certification.

1. When granted Certification, WHO publishes the certification in the weekly Epidemiological Record, International Travel and Health and the World Malaria Report; the country is listed in the official WHO Register of areas where malaria elimination has been achieved.
2. Travellers from non-malaria endemic regions can travel into a country certified as having eliminated malaria without fear of local malaria infections and the potential inconvenience of preventive treatment measures. This has the potential to attract more visitors and boost socio-economic activities.
3. Certification of malaria-free status may be lost by a country with the occurrence of three or more indigenous malaria infections of the same species within a year in the same focus for three consecutive years.

Because certification represents recognition of considerable operational achievement, careful national investigations and consultations with WHO are conducted before a country’s malaria-free certification status is lost.

1. Cabo Verde would be the first member state in Sub-Saharan Africa in 50 years to eliminate malaria; the last country and only country certified in Sub-Saharan Africa was Mauritius in November 1973.
2. Carbo Verde is also the second country to be certified for malaria elimination in the WHO/AFRO region (which extends beyond sub–Saharan Africa) in four years after Algeria, which was certified in May 2019. The certification of Cabo Verde thus represents a significant public health milestone for Africa.
3. Malaria elimination was achieved in Cabo Verde due to remarkable leadership and demonstrable multisectoral action by stakeholders following a malaria outbreak in 2017 in Cabo Verde, having interrupted malaria transmission on two previous occasions. Efforts to respond to the 2017 malaria outbreak were complimented by mainstreaming awareness raising, substantial investments to maintain technical capacities among health workers and efforts to address some of the underlying factors leading to recurrent outbreaks in the recognized and mapped previous foci of malaria transmission.
4. Notable is the high level of awareness of the link between the aspirations to maintain a malaria-free status with the launch of an integrated plan for the prevention of re-establishment with financial commitments from the ministries of tourism as well as agriculture/water resources in recognition of the strong tie between cross-sectoral growth potential and maintaining malaria-free status. This represents best practice in sustainable development models.
5. Taking the opportunities to prepare for certification over the past two years,systems and capacities have been strengthened with intensive efforts, with significant investment and support from the WHO and partners, strengthening health resilience, especially in laboratory diagnosis and integrated vector control. This will ensure better management of other vector-borne diseases, such as dengue fever.

• • Certification of malaria elimination is not a guarantee of a permanent malaria-free status. Sustaining malaria elimination requires that interventions and measures are implemented continuously to prevent the re-establishment of the diseasein all the country's territories.
  • There is a risk of malaria in Cabo Verde due to the continuous malaria importation from endemic countries, the presence of malaria vectors and the suitable ecological environments and climate. ​​​​​​​

• The certification confirms the malaria-free status in a country and recognizes that the entire territory has an adequate system for preventing the re-establishment of local malaria transmission. This will provide reliable information on the global distribution of malaria, which is necessary to assess the risk of international travellers' exposure to malaria and the epidemiological risk of importation of malaria parasites into malaria-free areas that are receptive to transmission.
• Cabo Verde will be required to continue reporting to WHO annually on maintaining their malaria-free status. The minimum indication of possible transmission re-establishment is the occurrence of three or more locally acquired malaria infections of the same species per year in the same focus for three consecutive years.
• Because certification represents recognition of considerable operational achievement, a careful national investigation and consultation with WHO will be conducted before a country's malaria-free certification status is lost. To date, no certification has been withdrawn.

• Some modest progress has been achieved concerning malaria elimination in other countries in the WHO/AFRO region. Six of the twenty-five countries identified globally as having high prospects of attaining malaria elimination by 2025 are in the WHO African region. These include Botswana, Cabo Verde, the Comoros, Eswatini, Sao Tome and Principe, and South Africa.
• Available country reports indicate that indigenous (local) malaria cases remain low in Botswana, Eswatini and South Africa. There have, however, been some reported recent increases in Comoros and Sao Tome & Principe.
• Countries need to set up National Advisory bodies on Malaria elimination to support policy implementation and multisectoral response for malaria elimination, monitor and evaluate the implementation of malaria elimination activities and ensure that accountability mechanisms are implemented to achieve progress. 
• Other Sub-Saharan African countries with low and moderate malaria transmission could also apply elimination principles to achieve sub-national elimination and accelerate reduction in the overall burden of malaria morbidity and mortality.
• These countries can achieve elimination by following similar steps taken through strong leadership demonstrated by Cabo Verde, such as:
  1. Strengthening health system infrastructure to improve access, coverage, and quality of care, especially related to malaria diagnosis, treatment and vector control.
  2.  Strengthening the disease and vector surveillance systems to use data for a timely and effective response
  3. Building capacity of human resources using local institutions to accommodate the needs in the malaria elimination phase and ensure the sustainability of efforts.
  4. Adapt the program’s Advocacy, Communication and Social Mobilization strategies aligned with the malaria elimination phase.
  5. Strengthening multisectoral collaboration and ensuring adequate resource mobilization ​​​​​​​