By Zheng Qi 2020-08-25

The precise, operational definition of what constitutes “malaria elimination” versus “malaria eradication” has evolved significantly over the decades, shaped by lessons from past campaigns, advances in surveillance science, and a deepening understanding of the complex biology of the Plasmodium parasite. In the early and mid-20th century, during the era of the Global Malaria Eradication Programme launched in 1955, terminology was often used more aspirationally and interchangeably, with ambitious timelines sometimes outpacing technical and operational realities. Today, after decades of refinement by the World Health Organization (WHO) and the global public health community, these terms carry distinct, carefully calibrated meanings that guide policy, investment, and measurement.

‌Current Definition: Elimination‌

Currently, in official WHO terminology and global malaria strategy documents, ‌elimination‌ is defined as the ‌interruption of local mosquito-borne transmission of a specified malaria parasite species in a defined geographical area‌. Crucially, this interruption must be sustained – it is not a temporary absence of cases but a continuous state achieved and maintained through deliberate intervention. While the area can be subnational (such as a province or island), the term is most commonly and meaningfully applied at the ‌country level‌. When a country achieves elimination, it demonstrates zero incidence of indigenous cases of the targeted malaria parasite(s) for at least three consecutive years, with a fully functional surveillance system capable of detecting, investigating, and containing any potential reintroduction. It is a monumental national achievement, but it does not mean the country is free from risk; imported cases from other endemic regions can still occur, requiring a strong “prevention of re-establishment” programme to maintain the eliminated status. This country-by-country approach, validated through a rigorous WHO certification process, forms the building blocks of the global eradication goal.

‌Current Definition: Eradication‌

In contrast, ‌eradication‌ represents the ultimate, permanent endpoint. It is defined as the ‌global interruption of transmission of a malaria parasite species, resulting in the permanent reduction of its worldwide incidence to zero, with no risk of reintroduction‌. This means that ‌all countries‌ have achieved and maintained elimination, and the parasite has been wiped out from the human population globally. Eradication implies that interventions (like drugs, insecticides, or vaccines) are no longer needed, as the pathogen no longer exists in nature in a form that can infect humans. It is a state of lasting, worldwide freedom from the disease. The only human infectious disease ever eradicated is smallpox, a milestone certified in 1980, which serves as both an inspiration and a reminder of the immense biological, technical, and socio-political challenges involved. For malaria, eradication would require not only eliminating the parasite in every endemic country but also addressing complex biological reservoirs (like P. knowlesi in non-human primates) and ensuring surveillance and response capabilities are sustained globally until the threat is irrevocably gone.

‌The Strategic Pathway: From Control to Eradication‌

These definitions are not just academic; they map onto a strategic continuum that guides global action:

‌Control:‌ The ongoing process of reducing malaria disease burden (morbidity and mortality) to a locally acceptable level through continuous intervention.

‌Elimination:‌ The country-level goal of stopping local transmission, moving from control to a phase of preventing re-establishment.

‌Eradication:‌ The global goal of terminating all transmission everywhere, forever.

The 2019 report of the WHO Strategic Advisory Group on Malaria Eradication (SAGme) reinforced this distinction, concluding that while eradication is a biologically and technically plausible goal, it is not feasible with today’s tools and health systems. The report emphasized that accelerating progress toward ‌national and regional elimination‌ is the most critical and actionable step on the pathway, as it drives innovation, strengthens health systems, and shrinks the malaria map—creating the essential foundations upon which a future global eradication effort could one day succeed. Thus, the clear separation of “elimination” (a country-level, achievable milestone) from “eradication” (the ultimate global goal) provides a crucial framework for realistic planning, targeted investment, and measuring tangible progress in the decades-long fight to end malaria.

Edited by: Secretariat of the Asia-Pacific Network for Drug and Diagnostics Innovation
Produced by: Zheng Qi
Reviewed by: Zhang Haobing
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