Malaria Manual of Procedures 2018

MALARIA MANUAL OF
OPERATION
FOREWORD
The Malaria landscape has changed tremendously in the last ten years. More provinces have been declared
malaria free and many provinces have zero malaria case in the past two to three years. By the end of 2017, malaria
cases in the country have been reduced by 93% compared to the 2003 baseline. Deaths have been reduced by
99% compared to the same baselines (142,000 cases to 4,038 cases and 164 deaths to 3). The geographical
extent of locally transmitted/indigenous malaria cases have been reduced to 181 barangays in 36 municipalities in
7 provinces from the previous malaria endemicity coverage of 15, 686 barangays in 487 municipalities in 53
provinces. A total of 42 provinces have been officially declared by the department as malaria-free provinces. The
target is to increase the number of malaria-free provinces to 72 by the end of 2020 for the last Philippine province
to reach elimination no later than 2024 en route to achieving country-wide elimination status by 2030. Efforts must
be exerted to ensure that every step in the transition to elimination status is properly documented. A robust amount
of information will be required to support our claim of country-wide disease free status when the country makes its
request for assessment.
Between now and then, we will continue to exercise eternal vigilance and enduring patience in ensuring that
whatever gains the program has achieved remains intact and protected. In those last remaining areas where
malaria remains a problem, quality health care, ready access to high quality health care services, both preventive
and curative should remain the norm of each and every health system at the national and local level, in both public
and private sector. The challenge is to accelerate these initiatives to levels where disease elimination is more
readily achieved, while at the same time, integrating and mainstreaming these activities into a regular,
comprehensive set of health care services for the community.
Critical recognition and acute awareness of this outstanding achievement will be instrumental in helping us sustain
this status and move towards our goal of country-wide disease free status.
This malaria manual of procedure embodies the struggle, dreams and aspirations of eliminating malaria using the
most advanced tools, socially and culturally acceptable interventions that is strengthening the local health systems.
The country’s program implementation, in line with the FOURmula One

for Health Plus or F1+ which expands the four pillars of health reforms
and highlights greater focus on performance accountability, is in the
forefront of these developments. Revision of the manual is necessary
to keep up with all these health reforms that are attuned to the needs
of frontline health workers. These updates conform with international
developments spearheaded by the World Health Organization (WHO)
to make it more responsive to the current state of malaria in the
country. The Philippines hopes to eliminate malaria by 2030.
National Malaria Control and Elimination Program Manual of Operations

Acknowledgement
The Department of Health National Malaria Control and Elimination Program would
like to thank the following organizations who provided people with expertise to form
this manual;
Asian Collaborative Training Network for Malaria Inc. (ACTMalaria)

DOH Epidemiology Bureau
DOH Health Promotion and Communications Service
Kilusan Ligtas Malaria (KLM)
Pilipinas Shell Foundation Inc. (PSFI)
Provincial Health Office of Laguna
Regional Malaria Program Coordinators, Entomologists and Microscopists
Research Institute for Tropical Medicine (RITM)
San Lazaro Hosp
UP PGH Collage of Public Health
World Health Organization (WHO)
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Abbreviations and Acronyms
AL Artemeter - Lumifantrine
AOPH Annual Operational Plan for Health
AP Active Province
APLMA Asia Pacific Leaders Malaria Alliance
BHW Barangay Health Workers
CHD Centre for Health Development
CHO City Health Office
DOT Directly Observed Treatment
GFATM Global Fund for AIDS TB and Malaria
GPS Global Positioning System
GTS Global Technical Strategy
IVM Integrated Vector Management
LGU Local Government Unit
LLIN Long Lasting Insecticidal Net
MESU Municipal Epidemiology Surveillance Unit
MFP Malaria-Free Province
MMC Municipal Malaria Coordinator
MSAT Mass Screening and Treatment
MTR Medium Term Review
NCDMFP National Committee for Declaration of Malaria Free Provinces
NCIP National Commission for Indigenous Population
NSPCEM National Strategic Plan for Control and Elimination of Malaria
NSP National Strategic Plan
OFW Overseas Filipino Worker
PACD Pro-active Case Detection
PESU Provincial Epidemiology and Surveillance Unit
PHA Philippine Health Agenda
PHO Provincial Health Office
PhilMIS Philippine Malaria Information System
PIDSR Philippine Integrated Disease Surveillance and Response
PIPH Philippine Investment Plan for Health
PMC Provincial Malaria Coordinator
PPCD Personal Protective Clothing and Devices
PQ Primaquine
PSFI Pilipinas Shell Foundation Inc.
QN Quinine
RACD Reactive Active Case Detection
RDT Rapid Diagnostic Test
RESU Regional Epidemiology and Surveillance Unit
RHM Rural Health Midwife
RMC Regional Malaria Coordinator
RSI Rural Sanitation Inspector
SDG Sustainable Development Goals
WHOPES World Health Organization Pesticide Evaluation Scheme
ZP Zero - Indigenous Province
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Contents
Acknowledgement ................................................................................................................................. i
Abbreviations and Acronyms .............................................................................................................. ii
Brief Introduction to the Manual ......................................................................................................... 1
Unit I Program Overview ............................................................................................................... 2
1 The Disease ............................................................................................................... 2
2 Global Malaria Situation ............................................................................................. 3
3 National Malaria Situation ........................................................................................... 4
4 Malaria Status of Provinces ........................................................................................ 5
5 Vision, Goal and Objectives........................................................................................ 6
6 Guiding Principles ...................................................................................................... 7
7 Policy Directions ......................................................................................................... 7
8 Strategies ................................................................................................................... 8
Unit II Epidemiology of Malaria .................................................................................................... 10
1 The Environment ..................................................................................................... 10
2 The Vector............................................................................................................... 11
3 The Parasite ............................................................................................................ 12
4 The Human Host ..................................................................................................... 13
Unit III Approaches and Interventions.......................................................................................... 15
1 Malaria Elimination ................................................................................................... 15
1.1 Malaria Elimination Strategy .............................................................................. 16
2 Prevention of re-introduction of malaria .................................................................... 17
2.1 Early Detection and Quality assured Diagnosis ................................................. 18
2.2 Readily Accessible Effective Treatment ............................................................. 18
2.3 Epidemiologic Investigation of cases and foci .................................................... 18
2.4 Coordination of responses to prevent indigenous cases .................................... 18
2.5 Foci Management in residual non-active and cleared foci and malaria free
provinces ..................................................................................................................... 18
3 Malaria Elimination Hub ............................................................................................ 19
3.1 Criteria and requirements for declaring provinces as malaria free .......................... 19
3.2 Certification Process .............................................................................................. 20
4 Stratification of Malaria Endemic Areas .................................................................... 21
4.1 Stratification of Barangays/Sitios ............................................................................ 21
4.2 Package of intervention per malaria focus .............................................................. 22
4.3 Stratification Records and Foci Registry................................................................. 22
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4.4 Classification of Provinces ..................................................................................... 22
5 Disease Surveillance ................................................................................................ 23
5.1 Malaria Case Detection ..................................................................................... 24
5.1.1 Active case Detection (ACD) ............................................................................... 24
5.1.2 Passive Case Detection (PCD) ...................................................................... 26
6 One-Three–Five (1-3-5) Response Strategy ............................................................. 29
Implementation Guide .................................................................................................. 29
7 Confirmatory Diagnosis of Malaria ............................................................................ 37
7.1 Malaria Microscopy ................................................................................................ 37
7.2 Rapid Diagnostic Test (RDT) ................................................................................. 39
7 Malaria Case Management....................................................................................... 43
8.1 Uncomplicated Malaria ........................................................................................... 43
8.2 Complicated Malaria .............................................................................................. 53
9 Malaria Vector Control .............................................................................................. 58
9.1 Long Lasting Insecticidal Net (LLIN) ....................................................................... 59
9.2 Indoor Residual Spraying (IRS) .............................................................................. 61
9.3 Integrated vector management (IVM) ................................................................ 63
10 Health Promotion .................................................................................................. 64
.................................................................................................................................... 66
Malaria Communication Plan ....................................................................................... 70
UNIT IV Program Management ................................................................................................... 71
1 Implementation Arrangement .................................................................................. 71
2 Planning ................................................................................................................... 71
2.1 Annual Operational Plan ........................................................................................ 71
2.2 Activities/Strategies at the Municipal and City level ................................................ 72
2.3 Activities/Strategies at the Provincial Level ............................................................ 74
2.4 Activities/Strategies at the Regional Level .............................................................. 75
2.5 Activities/Strategies at the National ........................................................................ 76
3 Logistics Management.............................................................................................. 77
.................................................................................................................................... 77
3.1 Malaria Commodity Stock Level for Malaria-Free and Zero Indigenous Provinces . 78
4 Reporting and Recording .......................................................................................... 79
4.1 Local Records and Reports .................................................................................... 80
5 Program Monitoring and Evaluation ........................................................................... 80
5.1 Monitoring by the National and Regional Level ...................................................... 81
5.2 Monitoring at the RHU/CHO and PHO Level .......................................................... 81
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5.3 Malaria Program Indicators .................................................................................... 84
5.4 Monitoring Progress of Malaria Elimination at the Provincial Level ......................... 84
6 Quality Assurance .................................................................................................... 85
6.1 Quality in Malaria Rapid Diagnostic Tests .............................................................. 85
6.2 Quality Assurance for Microscopy .......................................................................... 85
6.3 Quality Assurance in Vector Control ....................................................................... 88
Bibliography ........................................................................................................................................ 90
List of Figures ..................................................................................................................................... 92
List of Tables ....................................................................................................................................... 93
List of Annexes ................................................................................................................................... 95
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Brief Introduction to the Manual
The country is aiming for a Malaria Free Philippines by 2030 or earlier. This manual was written
for the LGU health workers multi-tasked by the numerous health programs to answer the
health needs of the community. The manual was simplified and condensed for easy
understanding the roles they must do to eliminate malaria in every corner of the country. The
risk of re-introduction of the parasite is always present coming from outside the country and
from the remaining active foci of malaria locally. This manual introduces 1-3-5 response
strategy to prevent re-introduction of malaria and integrated malaria control method to
eliminate malaria in the remaining active malaria foci. There is new stratification process and
new terminologies to conform to global technical strategies. Brief definitions and explanations
are inserted in the text for easy understanding. The progress of the program is faster than
expected and with the vigilance of every health worker malaria elimination is within reach. This
manual will guide them to search for the remaining malaria parasites in the community.
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Unit I Program Overview
1 The Disease
Malaria is a parasite that reproduces in the mosquito, inside human red blood cells (RBC) and
in the liver cells. They reproduce inside the RBC then burst the cell releasing substances that
induce chills, fever and sweating producing the classical symptoms of malaria (Fig. 1.1).
Released parasites invade another RBC. The cycle repeats every 48 to 72 hours. Thousands
of RBCs are destroyed with each cycle resulting to anaemia weakening the human body.
Some malaria parasites, instead of replicating develop into the sexual stage called
gametocytes. Gametocytes are picked up by mosquitoes where they undergo maturation and
sexual reproduction. After about ten days, they are transmitted as sporozoites to another
human when mosquito takes another blood meal. The parasites invade liver cells of the new
victim, reproduce and burst the host liver cells releasing thousands of parasites into the blood.
The life cycle goes on until it is interrupted by mosquito control and treatment of humans
hosting the parasites.
Fig. 1.1 Malaria Paroxysm
There are four species of human malaria namely: Plasmodium falciparum (Pf), Plasmodium
vivax (Pv), Plasmodium malariae (Pm) and Plasmodium ovale (Po). Seventy percent (70%) of
all malaria cases in the country are P. falciparum. It is also responsible for severe or
complicated malaria causing mortality. P vivax causes about 30% of cases. It is also capable
of producing complicated malaria but to a lesser extent. Plasmodium vivax (Pv) and
Plasmodium ovale (Po) have dormant stages in the liver called hypnozoites. They are the
causes of relapsing malaria several months or maybe years after the initial infection.

2 Global Malaria Situation
Global malaria incidence is on the decline since 2009 because of increase funding and large
scale implementation of interventions (WHO, A Framework for Malaria Elimination 2017).
Ninety one (91) countries and territories reported malaria transmission in 2015 (Fig 1.2). There
was 41% reduction of cases from year 2000 to 2015. There were 429,000 malaria deaths
globally in 2015. Ninety two percent (92%) of malaria deaths were from WHO African Region.
Children below 5 years old contributed 72% of all malaria deaths globally (World Malaria
Report 2016). Acceleration of reduction of incidence occurs after the introduction of better
medicines (Artemisinin-Lumefantrine combination therapy), insecticide treated nets and
increase in funding support.
Decrease in incidence rates is estimated to have been greatest in the WHO European Region
(100%) and the WHO South-East Asia Region (54%). In Southeast Asia and Pacific regions,
malaria is still considered a problem in Papua New Guinea, Lao People’s Democratic Republic
and Solomon Islands. The countries of Malaysia, South Korea and China are aiming to
eliminate malaria by 2020.
Malaria elimination is the buzz word today. Thirty one (31) countries have eliminated malaria
and have been certified malaria free by the WHO since 1955. Seventeen (17) countries
attained zero indigenous cases for 3 years or more between 2000 and 2015.
Malaria is fighting back. A pocket of drug resistance to artemesinin was identified in Mekong
sub region. This is a big threat to global malaria elimination. Containment of artemesinin drug
resistant malaria is going on through the leadership of the World Health Organisation, but drug
resistance can happen anywhere if medicines are not properly used.
Fig. 1.2 Malaria Endemic Countries (source: WHO, 2016 World Malaria Report)

3 National Malaria Situation
The Philippine Malaria Program Mid-term review (MTR) showed that the national malaria
program achieved the targets earlier than expected. The reduction of incidence is 66% since
2010. Total reported malaria cases in 2016 were 6604. Palawan Province contributed 92%
(6132) of the total reported cases. Among 81 provinces of the country, only 8 have indigenous
malaria, 32 are certified malaria free and 41 have no indigenous malaria. Out of 1634
municipalities in the country, malaria is only present in 40 (2.4%) municipalities. Eighteen (18)
of 40 municipalities contributed 98.3% of all reported malaria cases. The problem area had
shrunk as shown in the malaria endemicity map (Fig 1.3) (Table 1.1).
The problems in the 8 remaining provinces are diverse. Political instability, armed conflict and
cultural practices of the IPs are challenging and may need the involvement of other disciplines
or sectors. The current malaria situation is awesome but fragile. Outbreaks may occur. This is
the risk the provinces is facing because of increase in vulnerability owing to loss of natural
immunity over time coupled by mobility of population for various reasons. In 2014-2015 cases
increased by 65% contributed by Palawan Province brought about by delay in vector control
and increase in case detection activity by deployment of RDT to more sites.
MTR recommended improvement in the quality and timeliness of diagnosis and adherence to
treatment protocol, continue to expand and maintain the availability of RDT diagnosis by
BHWs in peripheral areas with persisting malaria transmission or risk. Regarding vector
control it is recommended that practices and evidence for vector control interventions should
be reviewed and rationalized under an updated focal approach to stratification. In areas where
cases approach or reach zero, strong surveillance is necessary and timely response with
aggressive vector control only in special risk situations.
In the area of human resource, MTR recommended strengthening of capacity at the LGU level
particularly entomology, vector control and microscopy quality assurance. Elimination hubs
must strengthen surveillance and have staff capable of analysing and responding to emerging
situations
Program monitoring, integrated surveillance and effective case investigation and response at
the community level should also be strengthened with particular emphasis on foci of
transmission. Careful, intensive and more frequent monitoring from central and provincial level
is needed in problem areas.

Fig. 1.3 Malaria Endemicity Map, 2010 – 2016
4 Malaria Status of Provinces
The vision of the program is a malaria-free country by 2030. The program is pursuing sub-
national malaria elimination. The Department of Health (DOH) certifies the province as malaria
free if they meet certain conditions particularly the ability to sustain malaria free status.
Provinces are in different phases of transition. Provinces in the zero indigenous malaria are in
the process of satisfying the criteria needed for declaration particularly sustaining their zero
malaria status through heightened surveillance and building capability to respond rapidly.
Provinces with barangays stratified under active transmission area are classified under active
province or A province. Indigenous cases occur in these provinces. When they succeed in
interrupting transmission and after a year of zero indigenous case, the province is classified
as zero indigenous province or Z province. The country must show the capability of rapid
response to a malaria case and the communities ready to cooperate. They need 3 years of
zero indigenous cases after which they can request the DOH for preliminary assessment. They
will be certified malaria free after 5 years of zero indigenous case and pass the assessment
for malaria free status. It is then classified as malaria-free province or MF province.
Table1.1 Category List of Provinces
Provinces with
indigenous Zero indigenous malaria (Z province) and
Criteria
malaria Malaria-Free provinces (MF province)
(A province)
Operational Interrupt
Prevent re-introduction of parasite
Objective transmission
Number of
8 73 (no local transmission)
Provinces

Ilocos Norte, Ilocos Sur, La Union, Pangasinan
Mountain Province, Kalinga, Apayao, Ifugao,
Abra
Batanes, Isabela, Nueva Vizcaya, Quirino,
Nueva Ecija, Bulacan, Pampanga, Bataan,
Tarlac, Zambales, Aurora, Cavite, Batangas,
Laguna, Quezon, Rizal, Marinduque, Mindoro
Cagayan
Oriental, Romblon, Masbate, Camarines Norte,
Davao del
Camarines Sur, Albay, Sorsogon. Catanduanes,
Norte
Cebu, Iloilo, Northern Leyte, Bohol, Guimaras,
Maguindanao
Biliran, Siquijor, Camiguin,
List of Mindoro
Negros Occidental, Negros Oriental, Antique,
Provinces Occidental
Western Samar, Southern Samar, Eastern
Palawan
Samar, Capiz, Aklan, Southern Leyte, Agusan
Sultan Kudarat
Del Norte, Agusan del Sur, Surigao Del Norte,
Sulu
Surigao del Sur, Dinagat Islands,
TawiTawi
Bukidnon, Lanao del Sur, Lanao del Norte,
Misamis Oriental, Misamis Occidental,
Compostela Valley, Sarangani, Davao del Sur,
Davao Oriental,
Zamboanga del Sur, Zamboanga del Norte,
Basilan, North Cotabato, South Cotabato
5 Vision, Goal and Objectives
Vision : A Malaria–Free Philippines by 2030
Mission : Further accelerate malaria control and transition towards

Elimination
Goal : By 2022, to reduce malaria incidence in the Philippines by 90%

relative to a 2016 baseline and to increase the number of
malaria free provinces from 32 to 74.
Objectives :
Objective 1 (Universal Access) – To ensure universal access to reliable diagnosis,

highly effective and appropriate treatment and preventive measures
Objective 2 (Governance and Human Resources) – To strengthen governance

and human resources capacity at all levels to manage and implement
malaria interventions
Objective 3 (Health Financing) – To secure government and non-government

financing to sustain malaria control and elimination efforts at all levels
Objective 4 (Health Information and Regulation) – To ensure quality malaria

services, timely detection of infection and immediate response, and
information and evidence to guide malaria elimination

6 Guiding Principles
The NSPCEM in the Philippines 2017-2022 is guided by the overall results of both reviews,
recognizing the varying status and individual circumstances of the different LGUs.
The Plan continues to pursue the achievement of the Sustainable Development Goal of ending
the epidemic of malaria infection in affected countries and the APLMA and ASEAN
commitments to achieving malaria elimination in the Asia-Pacific Region by 2030.
The strategies elaborated in the Plan take a health system strengthening approach to malaria
control and elimination (rather than, for example, including a separate objective relating to
health system functions). The updated NSPCEM also remains clearly and recognizably
aligned with the PHA of the new administration, and following a health systems approach
means that the strategies for both control and elimination areas can be addressed under the
one service delivery objective (but as clearly differentiated strategies).
In particular, the principal objective of the Plan (Objective 1) reflects the administration’s
fundamental guarantee in relation to service delivery in the health sector: universal access to
quality health care and services at all life stages. The technical approaches supporting this
objective are strongly guided by Pillars 1 and 2 of the WHO GTS and Regional Framework.
Other objectives are also recognizably aligned with other guarantees and/or major strategies
of the PHA, and with Pillar 3 and the supporting elements of the GTS and Regional
Framework: strengthening Program governance; rationalizing and, where necessary,
strengthening the malaria work force; maintaining the financing needed to sustain progress
towards accelerated malaria control and elimination (including through improved utilization of
PhilHealth financing for malaria diagnosis and treatment as a component of primary health
care, especially among the poor); strengthening information systems; and ensuring strong
regulatory and quality assurance (QA) functions.
7 Policy Directions
Overall Policy Direction
Efforts will be geared towards accelerating the program towards elimination, attainment of
malaria –free status and prevention of reintroduction.
Policy Direction 1
Area stratification down to the barangay/sitio level will be applied on the basis of rate of
transmission to guide the application of appropriate package of interventions and prioritization
of resources. Provinces reaching zero indigenous malaria will reclassify their barangay
following the elimination framework stratification of malaria endemic foci with its corresponding
intervention packages.
Policy Direction 2
The program will ensure universal access to early diagnosis and prompt treatment.
Microscopy remains the gold standard for malaria diagnosis. Rapid Diagnostic Tests will
complement microscopy in situations where microscopy will not be immediately available.
Treatment must make use of effective anti-malarial drugs, with guidance from results of up-to-
date efficacy studies done in the country.

Policy Direction 3
Universal coverage of vector control measures will also be ensured. Use of insecticide treated
nets (ITN), particularly the more cost-effective long lasting insecticidal nets (LLIN) is the main
vector control measure. Indoor residual spraying (IRS) with insecticide shall be adopted in
areas where the use of net is not culturally acceptable, displaced population and epidemic
situations. IRS will also be done with guidance from the results of epidemic and foci
investigations.
Policy Direction 4
Quality assurance for malaria microscopy, treatment and vector control measures will be
expanded to all endemic provinces, cities and municipalities, and must be sustained in
malaria-free areas
Policy Direction 5
Malaria surveillance will be used as a core intervention aimed at detecting suspect malaria
cases and confirming every infection for proper classification and management particularly in
areas that have been assessed to have interrupted transmission and/or declared malaria-free.
Epidemic management and response will be integrated with the Philippine Integrated Disease
Surveillance and Response (PIDSR) and established at all levels of administration.
Policy Direction 6
Health Promotion will be enhanced through the delivery of key messages focused to each
group of stakeholders and according to the stratification category of areas.
Policy Direction 7
Local capacities of malaria program management will be strengthened and coordination
among and between levels of administration relative to malaria program efforts and resources
will be streamlined.
Policy Direction 8
Efforts will be exerted for LGU’s to design or adopt financing mechanism to sustain malaria
operation towards elimination and to maintain their malaria-free status.
8 Strategies
Strategy 1.1 Maintain focal malaria interventions in municipalities and barangays with
active foci
Strategy 1.2 Ensure continuous access to malaria diagnosis, treatment and preventive
measures in zero-indigenous malaria and malaria-free provinces
Strategy 1.3 Implement responsive malaria interventions among identified vulnerable

population groups
Strategy 1.4 Increase demand for and support to effective anti-malaria interventions and
services
Strategy 2.1 Establish functional organizational structures and malaria work force at all
Levels
Strategy 2.2 Strengthen the policy environment, management systems and coordination
mechanism in support of malaria elimination

Strategy 3.1 Secure adequate government and non-government financial resources in
support of malaria control and elimination
Strategy 4.1 Ensure high quality malaria diagnosis and treatment, through effective quality
assurance systems
Strategy 4.2 Maintain high quality and effective vector control measures
Strategy 4.3 Strengthen malaria case surveillance and response systems in support of
malaria elimination according to the Malaria Surveillance and Response
Strategy
Strategy 4.4 Maintain effective malaria program monitoring and evaluation systems

Unit II Epidemiology of Malaria
1 The Environment
Environment consists of all the circumstances, people, things and events that influence life.
Living things have activities that change the environment (Fig 2.1). Increase of human
population puts pressure to the environment. Increase in human activities result to global
climate change which then influences every creature on earth. Malaria is no exception. Climate
change favours wider geographical distribution of mosquitoes thus increasing the potential for
wider malaria distribution too. Mosquitoes have survived extreme weather conditions. Their
population recovers fast. Water is the most important for their development and reproduction.
Seasonal increase of malaria cases is the result of seasonal changes in rainfall, creating more
streams where mosquitoes breed, and high humidity that prolongs the life of adult mosquitoes.
Longer life means more blood meals and egg laying and more mosquitoes and possibly more
malaria.
Fig 2.1 Interplay of factors in the environment determines malaria transmission.
Environment
Age
Human Parasite
Sex Parasite
Immunity Mosquito
Mobility
Rain
Water Humidity
Temperature
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2 The Vector
Rain creates water pools and streams where mosquitoes lay their eggs that favor abundance
of mosquitoes. It also provides high humidity prolonging their life span and increasing their
total egg output.
Development of the parasite from gametocytes to sporozites takes 9 to 12 days in the

mosquito gut. Infected mosquito remains infective for the rest of its life. High humidity during
the rainy season favors longevity of mosquito. Longevity of the infected mosquito is the most
important factor in the transmission of malaria. They take a blood meal every three days and
each bite transmits the parasites. Longer life means more bites thus more transmission.
There are five identified malaria vectors in the country. Their bionomics important for the
control program is listed in Table 2.1 below.
Table 2.1 Selected Characteristics of Malaria Vectors in the Philippines

An An. An. An. An.
flavirostris litoralis balabacencis mangyanus maculatus
Flight
range 1.5 -2.0 10.0-15.0 2.5 1.5 – 2.0 2.5
(in km)
Semi-
Slow flowing,
stagnant
fresh water
Small water Slow flowing streams
Breeding streams, Brackish
collection, rock streams in along sides
site shaded, water
pool, hoof tract wooded areas of shallow
abundant on
rivers with
foothills.
mat of algae
Peak
10:00 pm to 10:00 pm to 10:00–12:00
biting 8:00 – 10:00 pm -
2:00 am 4:00 am pm
time
Feeding Indoor and Indoor and Indoor and Indoor and
Outdoor
site outdoor outdoor outdoor outdoor
Resting Indoor and Indoor and
Outdoor Outdoor Outdoor
site outdoor outdoor
Mosquitoes can fly 1.2 to 2 km from breeding site unaided by the wind but An, litoralis can fly
10 to 15 km. Usually the mosquito fly within 500 meters from the breeding site to search for
blood meal. Houses nearest the breeding site are at higher risk and there are reports that they
tend to visit the same house. Table 2.1 shows the characteristics of the vectors useful for
designing vector control methods. Control methods can target the larval stages at the breeding
site or target the adult females in their resting and feeding sites. Only adult female mosquitoes
need a blood meal for the development of their eggs. They feed and lay eggs every 48 to 72
hours increasing the chance of exposure to applied vector control methods.
Mosquitoes can change their behaviour from indoor biter to outdoor biter and vice versa.
They can sense insecticide on sprayed walls and avoid it and they can develop physiological
resistance to insecticides contributing to complexity of malaria control and elimination.

3 The Parasite
There are four species of human malaria. Plasmodium falciparum (Pf) is the predominant
malaria species in the country at around 70% followed by Plasmodium vivax (Pv) at around
30%. Rare infection with Plasmodium malariae (Pm) is reported. Plasmodium ovale (Po) has
not been reported in the recent past. A fifth parasite, Plasmodium knowlesi (Pk) has been
identified in humans in Palawan Province, Philippines and neighbouring Malaysia. It is a
malaria parasite of the monkey.
Severe malaria is usually from Pf infection but recent literature reported Pv can also cause
severe malaria. Pv and Pm have dormant stages in their life cycle called hypnozoites
producing relapse several weeks or years after treatment of the initial infection. Hypnozoites
do not produce any symptom and no laboratory test is available to detect their presence in the
liver. Relapse may pose a challenge for malaria elimination. Some strains of Pv relapse more
often than others. They can relapse within 30 days to as long as 2 years.
Malaria parasites reproduce both sexually and asexually. Sexual reproduction happens in
mosquito. It is called sporogony producing sporozoites. Sporozites is the infective stage that
goes with mosquito saliva during blood meal. Schizogony is the asexual reproduction. It
happens in liver cells and in red blood cells (RBC). One complete life cycle of the parasite i.e.
gametocyte stage from one victim to gametocyte stage of the next victim, is called incubation
interval (Table 2.2). Keeping incubation interval in mind is the key to understanding malaria
control and elimination.
Table 2.2 Location and Stages of Parasite Life Cycle

Location Stages of Life Cycle Reproductive Phase
Human RBC Gametocytes (male &

(10 victim) female)
Zygote One incubation interval (25-35 days)

Ookinete
Sporogony
Mosquitoes Oocyst
(8 to 10 days)
Sporoblast
Sporozoites
Hypnozoites
(Pv and Po) Exo-erythrocytic
Human Liver Schizont
schizogony (12-15
(20 victim) (tissue)
Schizont days, longer in Pv) or
(tissue) Incubation Period
Human blood Erythrocytic
Merozoites
plasma cycle/schizogony
Trophozoites (ring form) (48 to 72 hours)
Human RBC merozoites invade
Schizont (erythrocytic) another RBC every time
they
Human blood mature,(symptomatic
Merozoites stage)
plasma
Gametocytes (male & Gametogony

Human RBC
female) (9-11 days in Pf)

The parasite life cycle has different stages in different location and they reproduce in each
location (Table 2.2). The number of offspring varies with species. Pf produces more offspring
(exo-erythrocytic cycle) than the rest thus producing more parasites that damage RBC
(Table 2.3). Pf makes RBC sticky blocking the capillaries of brain and other internal organs.
Table 2.3 Number of Offspring from a Single Parasite
Sporogony Schizogony(in humans)

Parasite Species
(in mosquitoes) Exo-erythrocytic Erythrocytic
(liver) (RBC)
Pf ~1000 30,000 8-24
Pv ~1000 10,000 12-14
Pm ~1000 15,000 8-12
Po ~1000 15000 6-12
4 The Human Host
Mobility
Both human and mosquito have the ability to move from one point to another. Humans carry
the parasites farther and more frequent than mosquitoes. Returning Overseas Filipino
Workers (OFW), armed groups, local and international tourists, seasonal workers, nomadism,
internal displacement and migrations are some of the reasons for mobility. Infected humans
carry the parasites with them wherever they go. They can re-introduce the parasites to the
community if the vectors are present. Malaria parasites can live in human body for 2 years or
more without treatment if they do not kill the host. Mosquitoes have limited flight range but
sometimes are accidentally carried by planes or ships to a more distant place.
Immunity
Lack of immunity predisposes individuals to development of severe malaria. People living in

non- endemic areas are not exposed to malaria hence no development of immunity. People
living in former endemic areas lose their immunity over time. Pregnant women have altered
immunity while children under five years old living in endemic areas have yet to develop their
immunity through natural exposure to the parasite. Semi-immune people in endemic areas
have mild symptoms or none at all. They have no symptom that prod them to seek medical
consultation therefore the infection is not detected. They are the undetected source of
parasites in the community sustaining transmission.

Behaviour
Human behaviour detrimental to malaria control and elimination are treatment seeking
behaviour and mosquito bite prevention. Each day of delayed treatment is a day of feeding
mosquitoes with parasites. Every night of unprotected sleep is a feast of parasite loaded meals
for the vector mosquitoes or vice versa.
Human behaviour provides complexity to malaria control. Improper intake of medicines
creates a chance for development of drug resistance.
Nightly use of mosquito net is another human behaviour needed to protect from mosquito
bites. Behaviour is the manifestation of the belief system. It has been ingrained into the
community and handed down through generations and offers a challenge to the program
especially among members of the indigenous population (IPs).
Living Condition
Mosquitoes can easily enter the house if the walls are not complete or there are gaps in the
walls, eaves or floor. Poverty maybe a factor in house construction but there are cultural
groups who prefer to have good ventilation by not completing the walls. Mosquitoes usually
visit the house nearest the breeding site and there are reports that they visit the same house
feeding in the same household.
Poverty dictates the living condition of the family and the community. Inadequate food
production, lack of education and poor health are conditions commonly found in malaria
endemic communities. Malaria pushes them further down to this cycle of poverty.
Society
Community members working together for common good have changed the course of the
disease in many areas both in and outside the country. The end goal of malaria elimination
and prevention of reintroduction is sustainable only if there is active participation of the
community members. Conflict between social groups, political groups, ideological groups or
cultural groups hinders delivery of health services thus favouring malaria transmission. These
are the challenges to the delivery of health services particularly towards malaria elimination.
Health Service Providers
Health service providers can change the course of the disease if they have commitment,
capability, coordination and control (4Cs). Experience has shown that without these 4Cs, the
disease will keep going on. Delayed intervention, stock outs of medicines, undetected malaria,
poor coordination among health units were just some of the reasons in the past for the
continuous presence of malaria after more than 50 years of malaria control service. Quality
assurance of health service delivery is necessary to move the program forward and eliminate
malaria once and for all.

Unit III Approaches and Interventions
1 Malaria Elimination
Policy Direction
Efforts will be geared towards accelerating the program towards elimination, attainment of malaria
–free status and prevention of reintroduction.
Malaria elimination is the interruption of local mosquito-borne malaria transmission resulting

to the reduction the incidence of infection caused by human malaria parasites to zero, in a
defined geographical area as a result of deliberate efforts with strategies containing measures
to prevent re-establishment of local transmission.
Malaria elimination does not mean complete elimination of disease-causing determinants such
as the mosquito vectors or the malaria parasites. It also does not mean complete absence of
reported malaria cases in a country. The focus is on local, active mosquito-borne infections.
Imported malaria cases are expected to continue to occur due sporadically due to the
migration and emigration of people brought on by international travel. (Malaria Elimination A
field manual for low and moderate endemic countries WHO; 2007)
Malaria transmission focus consists primarily of the mosquito vector breeding site and the
houses within the flight range of the vector (Fig. 3.1). The transmission focus is said to be
active if there is indigenous malaria case/s for the past 3 years, cleared if there is no
indigenous malaria case in the past 3 years. The focus is said to be receptive if the mosquito
vector exist even if there is no malaria parasite in the focus (A Framework for Malaria
Elimination, WHO, 2017). Confluence of transmission foci result to wider geographical
distribution of malaria. As the foci are cleared, the geographical distribution shrinks and what
remains are pockets of transmission focus. Reaching this stage increases the feasibility of
eliminating malaria.
Receptivity is the ability of the ecosystem to allow transmission of malaria.

Vulnerability is the probability of malaria parasite importation into a country or area.
A Framework for Malaria Elimination, WHO, 2017

Fig 3.1 Components of Malaria Focus
Mosquitoes can fly 2 km from the breeding site but observation and reports say they search
for blood meal nearest their breeding site usually within 500 meters and there are studies
that they usually visit the same household or the immediate neighbour.
1.1 Malaria Elimination Strategy
Program Policy Directions in transitioning from control to elimination
 Focused application of diagnostic and treatment and vector control measures
 Quality assured malaria interventions
 Continued funding support to sustain efforts for intensive control measures in

higher transmission areas, elimination strategies in areas with low transmission,
and prevention of resurgence in areas already declared malaria free
 Effective malaria elimination programmes with realistic targets expressed in a

comprehensive and funded plan of action, backed up by government commitment
at the highest levels.
 Adherence to national strategies and international standards

1.1.1 Surveillance
People coming into the community as well as residents who travelled in malaria
endemic areas or country must be tested for malaria. They must be kept under
observation for development of malaria symptoms for at least 2 weeks (incubation
period). Passive case detection (PCD) must be able to detect the relapse and
triggers another round of active case detection (ACD) to look for secondary cases
arising from the relapse case. Once the community is cleared of malaria,
surveillance through PCD will be the major activity to prevent reintroduction of
malaria.
1.1.2 Fortnightly ACD
Control methods must be applied simultaneously in the locality with active

transmission and ACD repeated every 2 weeks (fortnightly) to detect the parasite
emerging from incubation. Fortnightly ACD is crucial because gametocytes of Pf
appear on the second week of illness. It is a race of time between case detection
and treatment vs biting mosquitoes. Two incubation intervals without any case
detected in ACD is a good sign that the parasite is no longer in the community
except those who have hypnozoites in their liver. It can reactivate for as long as two
years or longer. Primaquine can kill parasite in the liver but since there is no
diagnostic method to recognise those who are harbouring the parasite in the liver,
they will be missed and the hypnozites reactivate later on to continue its life cycle.
PCD must be able to detect parasites emerging from hypnozoites stage.
1.1.3 Simultaneous intervention activities
Simultaneous interventions are the key to eliminate malaria in a transmission focus.

Malaria is an endemic disease. It circulates in localities with susceptible hosts and
mosquito vector. The parasite is dynamic. It does not stay in just one host owing to
nature of its life cycle. Program activities affect only one particular segment of the
parasite life cycle. Each segment must be considered a separate reservoir because
it can repopulate the other segments affected by the control method. Simultaneous
activities (health promotion + vector control + MBS then ACD) will eliminate parasite
in the community. Elimination activities have to be sustained because of
hypnozoites of P vivax and P ovale.
2 Prevention of re-introduction of malaria
Barangays/sitios classified as residual non-active and cleared may remain receptive to malaria
as long as the vector mosquito is present owing to the presence of suitable breeding site. The
threat of reintroduction is always present because of movement of people who maybe carrying
parasite from other endemic areas or from local people harboring hypnozoites from previous
Pv infection.

2.1 Early Detection and Quality assured Diagnosis
 Community members must be active in screening people visiting or migrating into
the barangay for the presence of malaria symptoms. It must be communicated to
community official and community members that their area is malaria free and they
should be always on guard to sustain their status.
2.2 Readily Accessible Effective Treatment

 Malaria medicines must be initiated within 24-48 hours of diagnosis. It has to be
available within few hours travel time. Medicine has to be effective to attain
parasitological cure and to prevent transmission of parasite. Delay in treatment
endangers the life of the patient.
2.3 Epidemiologic Investigation of cases and foci

 Every case of malaria needs to be investigated to determine the location of
transmission and places visited by the patient where it might have been
reintroduced. Each place visited by the patient must be investigated and placed
under heightened surveillance.
2.4 Coordination of responses to prevent indigenous cases

 Prevention of reintroduction is a community effort i.e. all stakeholders. It does not
necessarily mean residents of the barangay only or health sector only because
everything is at stake and many people will be at risk. Local health personnel must
not hide a case of malaria just to be safe from humiliation but they must ring the
alarm for the potential of local spread. Malaria is a disease with great epidemic
potential.
2.5 Foci Management in residual non-active and cleared foci and malaria free
provinces
 Community must also be active participants in bio-environmental management of
the breeding sites. Encourage the community to establish bio ponds where they
can raise larvivorous fish and seed the breeding site to control mosquito
population.
 Regular quarterly or semi-annual monitoring visit by RSI/MMC will encourage the
community to manage the foci themselves to keep mosquito population at low
level.
 Municipalities and cities should maintain a record of all foci and a map of their
municipality/city showing all the foci and the breeding sites with their GPS location
(longitude and latitude) and status of malaria transmission. (See Annex 2.)

3 Malaria Elimination Hub
Administrative Order no. 2013-0007 provided guidelines in the establishment of malaria

elimination response hubs in all malaria free provinces (including NCR) and areas which have
achieved zero indigenous malaria transmission. Malaria elimination response hub refers to a
structure equipped with diagnostic capabilities, entomologic surveillance capacity, laboratory
equipment and supplies, anti-malaria drugs and vector control commodities established in
areas malaria free areas to prevent the re-introduction of malaria. Presence of elimination hub
is criteria for declaring a province as malaria-free.
Elimination hub is manned by; (a) provincial malaria coordinator and other local health staff
trained on malaria surveillance; (b) entomologist-designate; (c) trained physician in malaria
case management; (e) health promotion officer (HEPO); (f) medical technologist/validator and;
(g) vector control response team. Elimination hub has to sustain malaria-free status of the
province/city through multiple interventions to prevent re-introduction of the disease.
Sub-National Malaria Elimination
The country embarks on eliminating malaria at sub national level. There are already 42 malaria
free provinces since the start of elimination campaign. There is progressive transition of
provinces from active to zero-indigenous status as a result of successful program. Provinces
are classified based on the occurrence of indigenous case/s:
a. Active Provinces or APs are those provinces still reporting indigenous cases.
b. Zero indigenous province or ZPs are those provinces without indigenous case of
malaria for the past 2 years or longer
c. Malaria-Free Provinces or MFs are those certified malaria free by the national program.
3.1 Criteria and requirements for declaring provinces as malaria free
Mandatory Requirements:
a. Absence of confirmed indigenous malaria cases in the last 5 years
b. Lab register – past 5 years
c. Surveillance reports in the past 5 years (including case/foci investigation

reports)
d. Presence of a functional malaria elimination response hub
e. Presence of a functional provincial surveillance system
f. Presence of a functional system for diagnosis and treatment of malaria
g. A line list of all health facilities (public and private) providing malaria diagnostic
and treatment services available anytime.

h. Compilation of all malaria reports in the past 10years.
i. Vector control report in the past 10 years (including QA of vector control) in the
past 5 years with entomological investigation reports
j. Functional entomological surveillance;
k. Functional quality assurance system for malaria microscopy (QA reports in the
past 5 years)
l. Cross border collaborations/operations
m. Sustainability plan next 5 years and budget utilization report in the past 5 years
n. Local Issuance/Ordinance on elimination hub requirements
o. Annual Operation Plan for Health (AOPH)/Provincial Investment Plan for

Health (PIPH) to support provincial malaria activities and operations
3.2 Certification Process
3.2.1 Self-assessment by the province

 The province conducts self-assessment based on their records and reports to
satisfy the mandatory and additional requirements mentioned above.
 Preparation of the Provincial /National Report
 Preparation of municipality reports
3.2.2 Validation by the regional office

 Review provincial report
 Regional Office validates the evidences for certification upon completion by the
province and endorse the provincial report National Office if all the
requirements are satisfied
3.2.3 Validation by the National Office

 National Office reviews the report, validates the completeness and consistency
of the reports and the readiness of the province to sustain malaria free status
upon endorsement of the regional office.
3.2.4 National Committee for Declaration of Malaria Free Provinces (NCDMFP)

approves certification

4 Stratification of Malaria Endemic Areas
Policy Direction
Area stratification down to the barangay/sitio level will be applied on the basis of rate of
transmission to guide the application of appropriate package of interventions and prioritization of
resources. Provinces reaching zero indigenous malaria will reclassify their barangay following the
elimination framework stratification of malaria endemic foci with its corresponding intervention
packages.
Malaria foci was defined as circumscribe area or formerly malarious area that contains the
epidemiologic and ecological factors necessary for malaria transmission. Malaria focus is
classified as active, residual non-active and cleared (Table 3.1) as adapted from WHO
Framework for Malaria Elimination (2017).
4.1 Stratification of Barangays/Sitios

Table 3.1 Classification of malaria foci
(source: WHO, A Framework for Malaria Elimination 2017)
Type of focus Definition Operational Criteria
Active A focus with going transmission Locally acquired case/s has
been detected within the current
calendar year.
Residual non-active* Transmission interrupted The last locally acquired case
recently (1-3 years ago) was detected in the previous
calendar year or up to 3 years
earlier.
Cleared* A focus with no local There has been no locally
transmission for more than 3 acquired case for more than 3
years years, and only imported or/and
relapsing or/and induced cases
may occur during the current
calendar year.
*These will revert to active foci immediately once an indigenous case is identified from the area.
Barangay will be the unit for stratification (or classification) of malaria focus. Barangay will be
subdivided further into locality if the barangay radius is more than 2 kilometres taking into
consideration the flight range of the vector. The package of intervention for each stratum is
listed in Table 3.3.
Prioritization among active foci will be through the string of months with indigenous cases if
the resources are limited.
a. First priority: Barangays/sitios with string of 6 months or more indigenous case/s in a

year for the past three years.
b. Second priority: Barangays/sitios with string of less than 6 months indigenous cases
in a year for the past three years.
Stratification is updated every year using the past three year’s data (moving 3 years).
Successful program implementation will show progressive reduction of Barangay/sitios from
active to residual non-active and eventually to cleared foci. When all barangays and sitios of
the provinces are cleared for 5 years they are eligible for certification as malaria free province
provided they meet the set criteria (page 23-24).

4.2 Package of intervention per malaria focus
Table 3.2 Package of intervention per malaria focus
Residual
Intervention Active Foci Cleared Foci
Non-Active Foci
Mop–up parasite Prevent Re-
Objective Prevent Re-introduction
pool introduction
Disease PCD PCD
PCD±ACD
Surveillance
Case-Foci
  
investigation
Response strategy Introduce 1-3-5 1-3-5 1-3-5
Microscopy or RDT
Diagnostic Method Microscopy or RDT If malaria is highly suspected... validate with PCR
Follow-up Smear Microscopy Microscopy

IVM approach
(LSM, where   
appropriate)
Continue to promote sleeping
LLIN  
inside mosquito net
Border operations (in areas bordering active foci) and
in Receptive areas with high vulnerability (evacuation
IRS Supplemental
centers, housing for workers – mining, military, forest
workers). Imported case in receptive areas (1-3-5)
 
Susceptibility (receptivity risk mapping; linked to the case/foci
Vector Surveillance
Testing investigation)
“Sleep inside “Seek early
“Seek early consultation”
mosquito net every consultation”
“Sleep inside mosquito net
night” “Refer people with
Health Promotion every night”
“Seek early Symptoms”
(Key Messages) “Refer people with
consultation” “Sleep inside
Symptoms”
“Refer people with mosquito net every
Symptoms” night”
Operational
As needed
Research
4.3 Stratification Records and Foci Registry

Stratification records among municipalities must follow the recommended format
(Annex 3). Municipalities must keep historical records of stratification for each
barangays/sitios by year. This will become the foci registry when the province
advanced to zero indigenous province or malaria-free province.
4.4 Classification of Provinces

Provinces are classified based on the presence of local transmission as follows:
1. Active Province (AP) refers to those provinces with active transmission in at least
one barangay or sitio.
2. Zero indigenous Province (ZP) refers to those provinces with zero-indigenous
malaria.
3. Malaria Free Province (MFP) refers to those provinces declared malaria free by
the Department of Health

5 Disease Surveillance
Policy Direction
Malaria surveillance will be used as a core intervention aimed at detecting suspect malaria cases
and confirming every infection for proper classification and management particularly in areas that
have been assessed to have interrupted transmission and/or declared malaria-free. Epidemic
management and response will be integrated with the Philippine Integrated Disease Surveillance
and Response (PIDSR) and established at all levels of administration.
Surveillance is the systematic collection, analysis, interpretation and dissemination of data for
use in public health action to reduce morbidity and mortality and to improve health. Malaria is
one of the reportable diseases in the Philippine Integrated Disease Surveillance and
Response (PIDSR) system, the main infectious disease surveillance and reporting system of
the Department of Health. It covers all cities and municipalities of the country including private
and government health clinics and hospitals. Surveillance provides data primarily for detection
of epidemics as well any other uncommon trend or pattern in disease occurrence and is the
basis for evidence based decision making in response to “out of the expected” occurrences of
the disease
PIDSR is first and foremost a surveillance system and not a regular Monitoring and Evaluation
system. It does not provide all the data needed by the program for decision making. The
implementation of the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) gave rise
to the demand for more in-depth and program-evaluating data and as a result, the Philippine
Malaria Information System (PhilMIS) was developed. However, it is limited to the provinces
supported by the Global Fund project.
Surveillance differs between Active (AP) Provinces and Zero Indigenous Provinces (ZP)
together with Malaria Free Provinces (MFP). As country progresses towards elimination
surveillance becomes more active. Malaria-free provinces and zero indigenous malaria
provinces aim to prevent re-introduction of parasite and to sustain their zero indigenous status.
Active provinces (AP) aim to reduce cases and their geographical spread and prevent
outbreaks through early detection, thorough assessment and prompt treatment of all cases.
Surveillance in malaria-free (MFP) and zero indigenous provinces (ZP) is proactive. Early
detection of suspect malaria cases, assessment, treatment and concomitant investigation to
assess risk of re-introduction is the cornerstone of surveillance activity. This approach is
embodied by the 1-3-5 surveillance strategy/approach. Establishing intensified facility-based
case finding based on re-defined standard case definitions and maintenance of access to
quality diagnostic facilities are the main working principles. Establishing regular screening
protocols for re-entering emigrants or visitors to malaria receptive community is
recommended. The process consists of an intensive personal interview of the migrant/visitor
a thorough physical assessment, determining if they fit the suspect malaria profile, undergoing
a confirmatory laboratory testing for malaria parasite and treat according to the prescribed
protocol if necessary. Directly observed treatment (DOT) is applied to those with malaria
positive smear and a series of weekly blood smear is taken to monitor the response to
treatment.

Table 3.3 Comparison of utilization of surveillance data between active provinces
(AP) and malaria free/zero indigenous malaria provinces (MFP/ZP)
Active Provinces (AP) Malaria Free (MFP) and Zero Indigenous
Malaria (ZP) Provinces
(1-3-5 approach)
MESU reports malaria cases every Friday Malaria case/s reported within 24 hours
PESU encodes data and send report to RESU Case Foci investigated within 3 days
PESU compares weekly incidence against Interventions (IRS/ACD/IEC) applied
previous year data of the same period within 5 days
PESU provides feedback to MESU Monitoring of cases on D 3,7, 28 for Pf and
extended monthly for 6 months for Pv
MESU provides feedback to MHO and MMC Screening of visitors, incoming migrants
and local residents who visited endemic
area
MHO and MMC decide the course of action
(please see response in page 27.)
5.1 Malaria Case Detection
Case detection can be classified into passive case detection and active case detection. It is
called passive case detection when patient seeks the health worker for consultation. Active
Case Detection (ACD) is the process of aggressively looking for fever cases in the community,
requiring a regular house-to-house visit by the health staff and volunteer workers to identify
cases. Active case detection (ACD) can be subdivided further to pro-active case detection
(PACD), reactive case detection (RACD), and mass screening and treatment (MSAT) formerly
called mass blood survey (MBS). Table 3.4 show the differences between ACD varieties.
Table 3.4 Varieties of active case detection

Type of ACD Procedure Objective
Proactive case detection Every house in the community is searched Lower burden of
(PACD) for people with symptoms who are then parasite in the
tested for malaria. community
Reactive case detection Household members of the index case and Gather evidence of re-
(RACD) immediate neighbors get tested for malaria. introduction of malaria
Mass Screening and Everyone in the community is tested for Search for
Treatment (MSAT) or malaria asymptomatic malaria
Mass Blood Survey carrier
(MBS)
5.1.1 Active case Detection (ACD)
Active Case Detection (ACD) is the process of aggressively looking for fever cases in the
community, requiring a regular house-to-house visit by the health staff and volunteer workers
to identify cases.There are several varieties of active case detection:
5.1.1.1 Pro-Active case detection (PACD).

The objective of PACD is to lower parasite pool in the community. It is
conducted by visiting every house in the community every 2 weeks and those
with symptoms (fever) are tested and treated if positive.

5.1.1.2 Reactive ACD (RACD)
The objective of RACD is to gather evidence of re-introduction of malaria. It is
done by visiting the household of a case under investigation and every member
of the household and their neighbours are tested for malaria regardless of
symptom. It is applicable to residual non-active and cleared and all barangays
of malaria-free and zero-malaria provinces.
5.1.1.3 Mass screening and treatment (MSAT) or Mass blood survey (MBS)
The objective of MBS is to look for asymptomatic malaria or malaria carriers. It
is conducted by taking blood smear of every individual in the community
(regardless of symptom) and those found positive are given treatment.
Steps in doing active case detection
1. Determine your objective (PACD, RACD or MSAT)
2. Determine resources needed

a. Human Resource
i. Med tech/Microscopist
ii. RSI Note: Determine whether the
iii. RHM microscopy will be onsite. This
iv. Field Assistant Workers will depend on accessibility of
the community. If microscopist
v. Transport Operator
will not be onsite there must be
provision that those found
b. Materials positive will receive treatment
i. Locality sketch map and demographic within 24 to 48 hours. Those
data with symptoms during the visit
ii. Glass slide maybe tested with RDT if
iii. Slide Box microscopy is not on site and if
iv. Blood lancet positive are treated
v. Cotton immediately.
vi. Alcohol
vii. Biosafety equipment
viii. RDT kits
ix. Anti-malaria medicines
x. Recording forms
xi. Transportation and other provision
3. Arrange the date of visit with the barangay official and emphasize need for total area
coverage.
4. On the date of visit, divide the team and assign areas to visit.
5. Visit every house and write the names of everyone staying in the house.
6. Ask if anyone have malaria symptom. Use RDT for immediate diagnosis and treatment
of those with malaria symptoms. Write the result of RDT and the treatment given in
ACD form.
7. Prepare blood smear of everyone who have no symptoms (for MSAT/MBS). If doing
PACD, take smear of those with malaria symptom and those who had malaria in the
past.
8. Dry the smear, label and keep in slide box.

9. Update the spot map for new houses and new individuals.
10. Remind everyone to sleep inside the mosquito net every night to prevent malaria.
11. Proceed to the next house and repeat Steps 6 to 10.
12. After visiting all the houses the team meets to consolidate the data and update the
locality map.
13. Have an exit conference with Barangay official and assure them you will provide
treatment for those who will turn positive for malaria.
14. Submit the blood smears for examination.
15. Return to barangay and administer treatment if there is positive smear. Prepare blood
smear of everyone living in the house with positives smear (for ACD).
16. Schedule the next visit 2 weeks later.
17. Follow-up Visit after 2 weeks. Coordinate with Barangay officials
Objectives of follow-up visit: (a) catch those who are in the incubation period and pre-patent period
during the previous visit, (b) follow up smear from those who completed treatment from previous visit,
(c) take blood smear of people staying with positive smear to identify asymptomatic carriers
18. Visit every house and search for people with symptoms of malaria.
19. Write the name of person with symptoms in ACD form and prepare blood smear.
20. Repeat Steps 10 to 17
21. Terminate the activity if there is no more positive smear for 4 consecutive visits (2
incubation intervals or 2 months).
Utilization of ACD data
ACD data provides a glimpse of malaria incidence on the day the activity was conducted. High
SPR (>2%) denotes high malaria incidence on that point of time (point prevalence). Mass
screening and treatment (MSAT) will provide better confidence about the real prevalence. It
will also provide information on proportion of Pf and Pv, gametocyte rate among Pf, fever rate
among positives and rate of asymptomatic infections. High proportion of Pf denotes high
transmission. If high proportion of Pv; moving towards elimination, treatment failure or Pv
outbreak. High gametocyte rate among Pf denotes late treatment seeking behavior and
probably higher incidence in the coming weeks or months. High asymptomatic implies high
level of partial immunity of the community. This information will guide program managers to
improve interventions.
5.1.2 Passive Case Detection (PCD)
Passively collected surveillance data is a tool of epidemiology. It provides information on

“what” is the problem (malaria incidence), “when” (weekly and monthly data), “where” (affected
barangays) and “who” (name, age, sex, occupation) are the affected population segment.
Possessing these information guides us “how” (decision making) to tackle the problem. Data
quality particularly completeness and timeliness will make decision better and appropriate.

Response for PCD detected cases
Objective of response in zero-malaria (ZP) and malaria free provinces (MFP) is to prevent
reintroduction of malaria parasite. This is also the response for barangays/sitios of active
provinces (AP) stratified under residual non-active and cleared barangays/sitio. The response
is rapid following 1-3-5 response strategy.
PCD surveillance data in active provinces
PCD surveillance data in control provinces is for monitoring the trend of malaria, for monitoring
impact of interventions and for stratification. Stratification is utilized for prioritization. PCD
Surveillance data for zero indigenous malaria provinces (ZP), malaria free provinces (MF) and
in barangays/sitios of active provinces (AP) under residual non-active and cleared strata must
follow 1-3-5 approach i.e. report within 1day, begin case/foci investigation within 3 days
following notification and plan and implement intervention within 5 days. The objective of the
response is prevention of reintroduction of malaria (Table 3.25)
Table 3.5 Response to PCD Malaria Report from Zero-indigenous malaria province
(ZP), residual non-active and cleared barangays of Active provinces (AP), and
malaria-free provinces (MF province)
Step Response Activity
1 Malaria case reported Go to step 2
2 Secure blood smear or RDT used to diagnose the case Go to step 3

Validate (cross read) the laboratory test. (if Positive treat accordingly
and do follow up smear on day 3 and day 28)
(if negative stop and consider other illness)
3 Investigate the case using Malaria investigation form .Investigation
Sheet (Annex 5) and classify
Imported Go to step 4
Indigenous Go to step 4
4 Investigate the focus using foci investigation form( Annex 6) and
classify according to receptivity and vulnerability
Receptive (with breeding site within 2 km radius)

Go to step 5
Vulnerable (with frequent influx of infected people)
Non Receptive (No breeding site) Go to step 9
5 Active case detection every 2 weeks

If negative continue PACD for 8 weeks Go to step 8
Positive Go to step 6
6 Do vector control (IRS or LLIN) Go to step 7
7 Mobilize the community to: Go to step 8

- Manage the breeding site
-Look for cases and bring to health center for laboratory diagnosis
- Campaign to sleep inside LLIN every night

8 Monitor vector control activity of community every quarter Go to step 9
Vector Surveillance (include larval dipping, carabao baited trap

(CBT))
9 Passive Case Detection Go to step 1

Update foci registry
Cities and Municipalities with Barangays/sitios classified under active foci but with an API less
than 1/1,000 population are recommended to adapt the 1-3-5 response strategy and develop
their structure and surveillance as such. The response in active foci is aimed at interrupting
transmission and preventing increase and spread (Table 3.6). They must follow the elimination
strategy as discussed earlier.
Table 3.6 Response to PCD reports from active foci barangays.

Step Activity
1 Monthly comparison of case compared to previous year Go to step 2
2 Increasing? Go to step 3
Decreasing? Continue monthly monitoring
3 Visit the community and do rapid assessment
Ask for:
LLIN use last night
Any movement of population into the area?(local population
who visited other areas, immigrants, OFW’s)
Do they seek early consultation?
Do they complete malaria treatment? Go to step 4
4 IEC campaign based on result of step 3 Go to step 5
5 Draw spot map (Google Map maybe use)
Plot the houses

Mark the house of the cases
Plot the breeding sites Go to step 6
No breeding site Go to step 7
6 Check the land area. Divide if the land area is more than 2km
(flight range of vector) from barangay proper
7 Delimit the area of transmission i.e. with cases and breeding Go to step 8
site
People maybe contracting malaria somewhere else if there is
no breeding site.
8 Consider supplementary IRS Go back to step 1

Request for bioassay of LLIN
Check quality of microscopy/diagnostic test

PCD Malaria Records
Hard copy of monthly record of cases by barangay/sitio must be printed because electronic
files can be lost from breakdown of computer system and computer viruses.
Data from PCD must be separate from ACD to avoid confusion during data analysis
particularly monthly incidence of the disease and SPR.
The recommended format for PCD record is illustrated in Annex 6. Monthly malaria record by
barangay/sito must be kept and updated at the end of each month. Comparing the data with
PESU record is desirable for uniformity and completeness. The table will come handy during
stratification, planning, monitoring and evaluation at the barangay level. This is also the
evidence to show active transmission in the barangay/sito.
String of transmission will show as string of months in the monthly record with malaria cases
in a particular barangay/sitio. A barangay/sito showing string of 3 months may need additional
control activity like supplementary IRS, community mobilization or ACD with IEC campaign for
regular use of mosquito net and early consultation and treatment. Interrupted transmission will
not show string of months with malaria in the monthly record of barangay/sitio.
6 One-Three–Five (1-3-5) Response Strategy
The Malaria Control and Elimination Program recognizes the need to sustain a functional and
robust surveillance system that will ensure that all suspect cases are immediately detected
and notified within 1 day (24 hours) of consultation. All notified cases are investigated
thoroughly to confirm the diagnosis and treatment and classify types of cases within 3 days of
notification, and focus investigation are conducted to each confirmed case within 5 days of
case notification to determine the types of the focus, and take actions within 5 days of case
notification to response to the intervention needs of different types of focus. This system,
briefly called as 1-3-5 strategy, transforms the control-oriented malaria surveillance system
into a core intervention to meet the need of a resilient malaria program for elimination. It aims
to prevent reestablishment of malaria in cleared areas.
The 1-3-5 response strategy is applicable in all provinces declared malaria free (MF), zero-
indigenous malaria provinces (ZP), and in municipalities with API <1/1000 population among
the 8 active provinces (AP).
Implementation Guide
6.1 Malaria case notification within 24 hours of consultation
6.1.1 Case Detection
6.1.1.1 All malaria suspects shall be subjected to malaria laboratory

diagnosis by either microscopy, RDT or by molecular modalities in
Barangay Health Stations, RHU center, Hospital or Private clinics.
6.1.1.2 Malaria microscopy or RDT shall be done within 24 hours upon

patient consultation.
6.1.1.3 Confirmed positive test must be treated immediately following the

treatment protocol. (See malaria treatment directory in page 46).

6.1.2 Case Notification
6.1.2.1 All confirmed and clinically diagnosed malaria cases are to be notified
through PIDSR within 24 hours upon patient consultation
6.1.2.2 For each confirmed or clinically diagnosed malaria case, the nurse or
physicians or other health worker shall send a notification within 24
hours to their respective Municipal Epidemiology and Surveillance
Unit
(MESU) or City Epidemiology and Surveillance Unit (CESU) via voice
calls or SMS and /or by other means with the following minimum patient
details:
i. Name;
ii. Sex;
iii. Age;
iv. Residential address of the patient
v. Malaria diagnosis and treatment given, if available
vi. Name, dress and contact details of facility/health worker
6.1.2.3 The MESU/CESU shall acknowledge the receipt of the notification via
voice calls or SMS and/or other means from the reporting local-health
facility. Notification is considered completed when the minimum
information has been confirmed received by the MESU/ CESU.
6.1.2.4 The MESU/CESU shall immediately inform the Malaria Program

Coordinator (MPC) of the City/Municipality. The MESU/MHO/MPC
shall immediately inform the PHO (PESU and PMC) of the reported
cases. The PHO shall be responsible in informing the RHO while the
RHO shall be responsible in informing the EB and the DPCD- IDO.
Exhange of information, depending on where the information
originates shall be vertical (up and down) and horizontal.
6.1.2.5 The MESU/CESU shall encode the patient details into the online
PIDSR software using the minimum information of the malaria case
from the local health facility/health worker.
6.1.2.6 In areas where online PIDSR is not available,the patient information

are encoded into the PIDSR offline version by which the mdb file of
the PIDSR can be sent at the end of each day.
6.1.2.7 Knowledge Management and Information Technology Services –

Immediate notification of each malaria case encoded in the Case
Investigation Form in the online PIDSR shall be sent to all other
administrative levels, Provincial, Regional and National level both for
the Disease Surveillance Units and the Malaria Program.
6.2 Malaria Case Investigation within 3 Days of case notification
6.2.1 The CESU/ MESU and the Malaria Program Coordinator shall jointly conduct
the case investigation within 3 days, using the Case Investigation Form in the
PIDSR (Annex 5).
6.2.2 The case investigation shall include confirmation/reconfirmation of the malaria

laboratory tests done/results which shall be done by the Provincial or Regional
malaria microscopy/RDT validator.

6.2.2.1 Not a Malaria Case – no further investigation shall be done. Seek
for other cause of the patient’s symptoms.
6.2.2.2 Confirmed Malaria Case – proceed with Malaria Focus Investigation
6.2.3 The case investigation shall also include review and confirmation of
management and treatment of malaria cases which can be performed by
the Provincial or Regional Malaria Program Coordinator.
6.2.4 Classify the malaria case’s type.
6.2.4.1 Indigenous Malaria Case

6.2.4.2 Imported Malaria Case
6.2.4.3 Induced Malaria Case
6.2.5 The Malaria Case Investigation shall be done and completed within 3
days upon case notification.
6.2.6 The Malaria CIF shall be accomplished and signed by both

CESU/MESU/PESU and the Malaria Program Point Person. The completed
Malaria CIF shall be encoded into the PIDSR (online or offiline) by the
MESU/CESU/PESU.
6.3 Focus investigation within 5 days of case notification
The purpose of focus investigation is to assess the risk of local transmission and
conduct appropriately response in the area of concern .The process of foci investigation
and classification can help evaluate the risk of onward or secondary malaria
transmission where the case was diagnosed or the case resides.
The area can either be classified as a focus or non-focus depending on the result of the
thorough investigation.The prescribed Foci Investigation Form (Annex 6) shall be used
in investigating all foci.
6.3.1 Focus Investigation

Focus investigation, administrated using Focus Investigation Form,
involves collection of the following information:
6.3.1.1 Basic information of the index case and the focus, including address,
population, geocoordinates, etc.
6.3.1.2 Environmental and ecological assessment – to collect the

information and data on altitude, topography and vegetation of the
surroundings of a focus,
6.3.1.3 Conduct of malaria vector survey including mapping of potential

breeding sites in the surroundings (2 km far from the residential
location of the index and newly found cases)
6.3.1.4 Review the previous focus classification of the area – Check the
database of foci registry/ annual classification

6.3.1.5 Review of Epidemiological Survey – (5 years)
Review malaria incidence in the past 5 years,
6.3.1.6 Cultural, Social and Economic assessment
6.3.1.7 Conduct reactive case detection:

6.3.1.7.1 The RACD includes rounds of screening of the 5 groups of
people, following detection of a local or imported case in a
receptive area (usually through ACD):
6.3.1.7.1.1 Family members
6.3.1.7.1.2 Neighbours
6.3.1.7.1.3 Co-workers
6.3.1.7.1.4 People in areas recently visited by the index case,
and populations living within the flight range of
anophelines from relevant breeding sites
The rounds should be continued at regular intervals, until no more cases are detected.
Fever may and may not be a criterion for testing, depending on resources and the
epidemiological situation.
6.3.2 Determine Receptivity
Receptivity of a site to malaria transmission depends on the presence of vectors and

the existence of environmental and climatic conditions favourable to malaria
transmission.
6.3.2.1 If a site is located at a very high altitude area or a highly urban

area (downtown only of the provincial capital cities in the
Philippines) with no vectors, then it is classified as non-receiptive
site, or
6.3.2.2 If current survey, as part of the focus investigation, or the surveys

conducted at the site in the past 5 years, reported presence of
any of the vectors for malaria (An. Flavirostris, An. Balabacensis,
An. Maculatus, An. Litoralis, An. Mangyanus, or other confirmed
Species of anophelines mosquito transmitting locally malaria),
then the site is classified as receptive site,or
6.3.2.3 If a site does not have past or present entomological evidence of

malaria vector presence, but its topography is either
mountainious/valley or coastal, its vegetation of surroundings is
forest, bush or rice/crop fields, and it has fresh water stream(s),
brackish water, swamps with fresh running water, it is classified
as receptive site. Otherwise, classifying it as non-receptive site.
6.3.3 Classify the Transmission Status of a Receptive Site

Once the receptivity of the area has been determined, a thorough review of
relevant data including environmental, ecological, epidemiological,
entomological, social and economic factors is essential to determine the
status of malaria transmission of a receptive site.

The status of malaria transmission is classified into the following three
categories:
6.3.3.1 Active: locally acquired case(s) have been detected within the
current transmission season or calendar year;
6.3.3.2 Residual non-active: the last locally acquired case(s) was detected
within the previous transmission season/calendar year or up to 3
years earlier; other kinds of cases may occur, i.e imported, induced
or relapsing/old cases.
6.3.3.3 Cleared: no transmission was detected within the last three years;
imported, induced or relapsing/old cases detected in current
calendar year or transmission season.
6.3.4 Determine the vulnerability of the receptive site

A focus is vulnerable if there is frequent influx of infected individuals or
groups or near the border of an active focus (within the flight range of the
vector).
6.4 Implementation of Response Interventions within 5 days of case notification

Once the focus has been classified, the malaria team shall implement appropriate
response according to the type of malaria focus.
6.4.1 Active Focus
6.4.1.1 Enhanced Passive Case Detection Services in health facilities

Review epidemiological data, including patient registration of RHU for
potential under-reported cases
6.4.1.1.1 RDTs be available at all levels of health facilities and

community level services
6.4.1.1.2 Quality-assured microscopy be available at hospitals and

malaria laboratories at health facilities
6.4.1.1.3 Supported by supervision at different intervals
6.4.1.1.4 Maintain available of malaria diagnosis and treatment

services
6.4.1.1.5 Test for malaria should be done for all individuals with fever
at least for the next 3 years from the day the index CASE
was detected.
6.4.1.2 Reactive Case Detection

To continue regular screening of the 5 groups of people at a focus
namely: family members of the index case; neighbors; co-workers;
people in the areas visited by the index cases; and population living
within the flight range of the anophelines from relevant breeding sites.

6.4.1.3 Treatment
Administer treatment to confirmed indigenous, imported, induced or
relapsing/old cases if any, and supervise the outcome of treatment.
All patients must have follow up smear at least on days 0, 3 and 28.
6.4.1.4 Vector Control
6.4.1.4.1 Identify vector’s species, susceptibility to insecticides being

used, and the time and location (indoor and outdoor) of
biting
6.4.1.4.2 Rapid assessment of the vector control strategies

implemented in the active foci to quantitate the access to
and use of LLINs and IRS, and to assess the quality of the
interventions in the foci (e.g., what is the condition of LLINs)
and insecticide levels present (whether on nets or applied to
walls)
6.4.1.4.3 Implement IRS and LLIN rapidly after detection of the active
focus
6.4.1.4.4 Implement supplementary vector control if justified
6.4.1.5 Health Education

Promotion of key messages such as acceptance and usage of LLIN
and IRS, acceptance to the screening and malaria tests, vigilance of
fever surveillance and for health workers to keep malaria as a
potential cause of illness of fever cases, and immediate consultation
to the nearest health facility for any fever cases.
6.4.2 Residual Non-Active Focus
6.4.2.1 Enhanced Passive Case Detection Services in health facilities

Same as that for active focus
Test for malaria should be done for all individuals with fever at least
for the next 3 years from the day the index CASE was detected.
6.4.2.2 Active case detection

Same as actives case detection in the population and initiate
reactive case detection to cases reported
6.4.2.3 Treatment
Provide treatment to any imported, induced or relapsing/old cases
detected. All patients must have follow up smear on days
1,3,7,14,21, and 28.
6.4.2.4 Vector Control

Same as that for active case detection but can be less intensive.
6.4.3 Cleared Focus
6.4.3.1 Passive Case Detection: Test should be done for all individuals
With fever at least for one year from the day the index CASE was
detected

6.4.3.2 Several rounds of active case detection as a minimum
6.4.3.3 Assessment of the risk of transmission, and decide if same vector

control may be needed depending on the magnitude of the risk
6.5 Register the Focus in the Foci Registry
The Malaria Focus database shall be updated as needed. PHO, RHO and DPCB shall keep
a file of the Foci Investigation form. The original form shall be kept by DPCB. The MHO shall
register the focus in the online focus registry and illustrated in a municipal map. The PHO
and RHO shall ensure that the foci registry is updated regularly.
Steps in the response strategy are illustrated in Table 3.7 below.
Table 3.7 Steps in 1-3-5 response strategy

DAY STEP ACTIVITIES NOTES
From all levels of health care
1 Malaria Suspect? ... Go to step 2 inclusive of private and public
clinics and hospitals.
Confirmatory Test (Microscopy or RDT) BSMP must be made among
RDT positives to establish
Negative …. Repeat the test after 8 to 24 baseline for case follow-up.
2
hours … STOP if test remains negative
Positive … Go to step 3
Treat case accordingly upon confirmation
of diagnosis (See Treatment Directory
3
page…) … Go to step 4
Report case to MESU, PESU and RESU Case notification can be through
within 24 hours with the following online/offline PIDRS or cellular
information: phones whichever is faster.
 Name
 Age
 Sex
ONE  Complete residential address of
4
(1) the patient
 Malaria Diagnosis and Treatment
given
 Name, address and contact details
of facility/health worker
… Go to step 5
MESU confirms receipt of notification and
together with MMC validate, investigate
and classify the case using malaria case
investigation sheet (Annex…)
 Imported
5  Relapse
 Introduced
 Indigenous
Go to step 6

MESU encode the data to PIDSR
6
MMC do reactive active case detection Immediate treatment of positive
(RACD) cases is a must.
THREE Introduced case/s … Go to step 8

7
(3)
No positive cases … Repeat 7 and STOP
after 2 rounds of no positive tests… Go to
step 13
Determine classification of focus from foci Once an indigenous case
registry appeared in residual or cleared
focus it immediately reverts to
Active focus … Go to step 10 active focus classification.
Residual focus … Go to step 11 Foci registry must be updated as

8 frequent as possible.
Cleared focus … Go to step 12
Municipalities must keep updated
Unclassified focus … Go to step 9 list of malaria foci.
Classification not updated … Go to step 9
Do focus investigation using the foci Receptive foci are those with
investigation form (Annex 5) malaria vector mosquitoes.
9 Receptive… Go to step 8 A receptive focus will have high

vulnerability if there is high
Non-Receptive… Go to step 13 population flow.
Activities for Active Focus See Stratification of barangays in

 Do integrated vector management pp.
(IVM) within 5 days from case
notification
10  Vector Control (LLIN/IRS)
 Reactive ACD
 Proactive ACD
 Health Education
Go to step 13
Activities for Residual Focus
 Enhanced PCD
FIVE  PACD + RACD
(5) 11  Treatment of cases
 Vector Control
 Health Promotion
Go to step 13
Activities for Cleared Focus
 ACD several rounds
 Assess risk of transmission
12  PCD
 Treatment of all positive cases
 Health promotion
Go step 13
13 Update/Register focus in foci registry See forms in Annex 2

7 Confirmatory Diagnosis of Malaria
Policy Direction
The program will ensure universal access to early diagnosis and prompt treatment. Microscopy
remains the gold standard for malaria diagnosis. Rapid Diagnostic Tests will complement microscopy
in situations where microscopy will not be immediately available. Treatment must make use of
effective anti-malarial drugs, with guidance from results of up-to-date efficacy studies done in the
country.
 Laboratory test is necessary to have a definitive diagnosis of malaria and have the
appropriate treatment because symptoms of malaria are similar to other febrile
illnesses.
 Negative test can be repeated after 24 hours if malaria is highly suspected especially
if patient have history of travel or come from a malaria endemic area or country.
 The program utilizes microscopy or rapid diagnostic test (RDT) to confirm malaria
diagnosis.
 Confirmatory tests, both RDT and microscopy, are subjected to quality assurance
process to cope with the rigours necessary for malaria elimination.
7.1 Malaria Microscopy
 Microscopy is the gold standard for malaria diagnosis. Microscopy demonstrates

malaria parasite in stained blood smears on a glass slide.
 Microscopy is performed by trained Med Tech or Volunteers who passed the required
proficiency rating in the basic malaria microscopy training.
 Proper collection, preparation, labelling, drying fixing, and staining of malaria blood
films to produce high quality, specimens for microscopy is a must.
 A standard blood smear has thick and thin blood film in one glass slide.
Equipment and Materials for blood smear preparation and examination
• Disposable lancet
• Glass slide (preferably w/frosted end)
• 70% Alcohol
• Cotton
• Pencil
• Gloves
• Bio Safety container for sharps (puncture resistant)
• Bio Safety container for infectious wastes
• Methanol (Absolute)
• Giemsa Stain
• Immersion Oil (Type A)
• Buffer salt or tablet
• Coupling jar
• Staining Rack
• Slide Rack
• Graduated cylinder (10 ml and 100 ml)
• Pipette
• Tally counter (min: 2-placer)

• Microscope
• Lens Paper
• Forms (result, registry, referral, etc.)
• Slide box
• Filter paper for blood spots
Procedure for preparation of Blood Smear for malaria microscopy
 Hold the patient's hand and select the third or fourth finger from the thumb. Use the
big toe for infants.
 Clean the finger/toe with a piece of cotton soaked with 70% alcohol, using firm strokes
to remove grease and dirt from the ball of the finger/toe.
 Puncture the ball of the finger/toe with a sterile lancet.
Precautions in preparation of blood smear

Wear gloves when collecting blood for malaria blood films
Use new, pre-cleaned and grease-free glass slides
Use new lancet for each patient. NEVER reuse blood lancets.
Always label the glass slides with the slide ID no., patient’s name, age, sex, date and
time of collection before taking a blood film.
 Apply gentle pressure to the finger/toe to express the first drop of blood and wipe it
away with a dry piece of cotton wool. Make sure that no strands of cotton remain on
the finger/toe as these cotton strands maybe mixed with the blood
 Collect 3small drops (approx.2 ul/drop) of blood on one end of the slide and 1drop on
the middle of the same slide as shown below.
 Prepare the thin film first. Place the slide on a flat surface, using another glass slide
as spreader, at an angle of 450 spread the blood away from the 3 drops. Push steadily
to have a tapering smear with feathery edge.
 Using the corner/edge of the same spreader, prepare the thick film by joining the three
drops of blood in a circular manner, starting from the outside going inward to make 1
cm diameter of blood film.

 Air dry the blood smear. When using a glass slide w/o frosted end, label the slide on
the thicker portion of the thin blood film. Indicate slide number, name of the patient,
slide number and date of collection using lead pencil as shown below.
 Send blood smear to laboratory for staining and examination. (See Annex 7 for
procedure of Giemsa staining method)
Blood Smear Examination Results
The microscopist records the data of the patient in the laboratory microscopy log book,
process the smear using Giemsa stain, examine the smear and release report using a
standard code as shown in Table 3.8 below.
Table 3.8 Code for Microscopy Result

Microscopy Report Code Code Interpretation
F P falciparum trophozites only
Fg P falciparum gametocytes only
F+g P falciparum trophozoite and gametocytes
F w/ schizonts P falciparum trophozoite and schizont*
F+g w/ schizonts P falciparum trophozoites, gametocytes and schizonts
V P vivax (any or all stages seen)
M P malariae (any or all stages seen)
O P ovale (any or all stages seen)
VFg Mixed infectionofP vivax and gametocytes of P falciparum
VF Mixed infection of P vivax and trophozoites of P falciparum
MFg Mixed infection of P malariae and gametocytes of P falciparum
MF Mixed infection of P malariae and trophozoites of P falciparum
Mixed infections of P malariae, P vivax and gametocytes of P
MVFg
falciparum
NMPS No Malaria Parasite Seen
Note: *Schizont of P falciparum in peripheral blood smear is indicative of severe malaria
7.2 Rapid Diagnostic Test (RDT)
 Rapid Diagnostic Tests detect malaria antigen in the blood of the patient.
 Test result is available within 15 to 20 minutes.
 Advantages of RDT lies in its simplicity, easy to use, requires little training, and do not
require electricity nor expensive equipment.

 RDT comes in different design as cassette, card or strip and different antibodies to
parasite antigens.
 The program deploys RDT in hard to reach areas through trained volunteers. Clinics
and hospital can use RDT in times of emergency, if there is no trained Med Tech and
in situations where no Med Tech is on duty.
RDT contains proteins (antibodies) that will deteriorate in high temperature and high humidity.
Observe required care during transport and storage to preserve quality.
Table 3.9 Target antigens of commercially available RDTs

Parasite Species Parasite Antigens
Histidine Rich Protein pLDH Aldolase
(HRP2)
Pf species 
Pv species 
Pan Specific (all species)  
Specific to some other species 
Materials for RDT
 RDT Kits
 RDT
 Blood transfer device
 Running Buffer
 Lancet
 Alcohol swab
 Gloves
 Dry Cotton Swabs
 Sharp Disposal Container
 Bio-hazard bag (same as in MM)
 Clock timer
 Pencil
 Ballpen
 Forms (same as in MM
Procedure for RDT
 Prick the finger to extract blood.

 Fill the required amount of blood using blood transfer device to well “S” (Fig 3.2)
 Put the required amount of buffer into well “A”
 Wait for the required reaction time and read the result
NOTE: Different RDT brand have different procedure. Read the accompanying
instructions carefully and follow them strictly. Different brands have different volume
of buffer and different reading time. Buffer is not interchangeable even if the brand is the
same.

Fig. 3.2 Sample of cassette type RDT (Different brands may have different design and
procedure. Always read the accompanying leaflet before using RDT kit).
Reading RDT Result
 Lines will appear after the prescribed reaction time. Line in C (control) means the test
is properly performed and the RDT is of good quality. More lines will appear if the blood
contain malaria antigen as shown below (Fig 3.3). See the accompanying leaflet with
the kit for the correct interpretation of the result.
 The test is not valid if there is no line in “C” and the test must be repeated even if
there is line in Pan &/or Pf.
 Some RDTs are designed for detection of Pf only and others are designed to detect
Pf plus other parasite.
 Be familiar with the available RDT in your clinic for proper procedure and correct
interpretation of results.
 Record the result in the RDT log book with the pertinent information of the patient.

Fig. 3.3 Appearance of RDT Cassette after reaction time with result lines
Criteria Appearance after 15 minutes Result
Invalid test
No line in C
Note: Repeat test

using a new
cassette.
P. falciparum
Lines in C
and
Pf
P. vivax
Lines in C
and
Pan
Note: It can also be
P.malariae or P.
ovale
Mixed infection
Lines in C
and Pan
and Pf

7 Malaria Case Management
Treatment of each case of malaria is both curative and preventive. The curative aspect
relieves the symptoms by using schizontocidal drugs. The preventive side kills the
gametocytes to block transmission and to prevent relapse in species that have hypnozoites.
Treatment for malaria must be based on a positive test by either microscopy or RDT. Negative
test can be repeated not neglecting to look for other causes of febrile illness. Negative test of
patients who are severely ill or unconscious do not prohibits anyone to manage the case as
malaria especially if the patient comes from a malaria endemic area or recently visited an
endemic area or stayed in malaria endemic country. Response to treatment must be monitored
closely especially if the case is imported from an African country or Mekong Sub-region. There
are anecdotal reports that patients from Africa do not respond well with first line treatment
given locally (Artemeter Lumfantrine) while in Mekong Sub region (Cambodia, Lao PDR,
Thailand) drug resistance to artemisinin has been identified.
Directly observed treatment (DOT) is the preferred approach particularly in malaria free and
zero-indigenous provinces. Completion of dose for every case is important to prevent drug
resistance.
Every treated case must have follow-up smear weekly for 4 weeks to monitor response to the
treatment. Follow up smear is extended monthly for 6 months to detect relapse if the infection
is from Pv or Po. Treatment failure must be reported to CHD for identification of drug
resistance. Adverse reactions to anti-malaria medicines must likewise be reported.
Treatment failure is presence of parasite in the blood smear anytime during the follow up period.
Malaria may present as uncomplicated infection or it can present as a complicated infection

i.e. there are life threatening conditions. Early recognition of complications can save the life of
the patient.
8.1 Uncomplicated Malaria
I Malaria Prophylaxis
Visiting the Countryside Prophylactic medicine is advised if visiting the 8 provinces with
indigenous malaria most especially if they are going to have “night time outdoor activities”,
otherwise, they can contact the local health unit for specific locality where they need to take
prophylaxis. More than 90 % of our country is free from malaria transmission and prophylaxis
has no practical value most of the times.
Working or Visiting other Countries It is best to follow the prophylactic treatment of

destination country. Do research before travel. Prophylactic medicines are to be taken before
reaching the destination to have adequate protection within the blood before potential
exposure to the parasite.
Mosquito Bite Prevention Health workers are credible and important sources of malaria
information according to previous survey. Health worker should inform the travellers how to

prevent malaria. Sleeping inside mosquito net, staying inside screened houses, use of
mosquito repellents, wearing long sleeve clothes and long pants will deter mosquito bites thus
prevent malaria.
II Medicines for Management of Malaria Based on Revised National Treatment

Protocol
Drugs for malaria and its complications are listed in Table 3.10 with their dose and available
preparations in the country. Anti-malaria drugs are seldom found in local drug stores. They
can be requested from elimination hubs of the provinces (MFP and ZP) and in the health
clinics/BHS of active provinces (AP).
Table 3.10 List of Medicines for Treatment of Malaria and Complications

Medicine Available Dose/kg body weight Remarks
preparations
Anti-malaria
Arthemeter 20 5-24mg/kg
Artemeter -
mg/
Lumifantrine
Lumefantrine 29-144 mg/kg
(AL)
120 mg
Contraindicated to children below
7.5 mg tab 1 year old, G6PD deficient
Primaquine
15 mg tab 0.25 mg/kg patients, pregnant women and
(PQ)
lactating mothers of infant whose
G6PD status is unknown.
Chloroquine Day 1&2 dose is 10 mg/kg
(CQ) 150 mg base/tab 25 mg/kg total dose Day 3 dose is 5 mg/kg
300 mg/tab 10 mg/kilo/dose May give 20mg/kilo loading dose
600 mg/tab (maximum dose of 2,000 for severe malaria
Quinine (QN)
300 mg/ml mg)
ampule
Vial of 60 mg 2.4 mg/kg/dose × 3 dose Shift to standard dose of A-L + PQ
Rectal q12h after the third dose (24 hours) if
Artesunate suppository patient can tolerate.
50 mg, 200 mg, Use 3mg/kg for patients
400 mg weighing less than 20kg
Clindamycin 300 mg/cap 10 mg/kg/day
Contraindicated to children less
Doxycyline 100 mg/cap than 8 years old and pregnant
mothers.
Contraindicated to children less
250 and 500
Tetracycline than 8 years old and pregnant
mg/cap
mothers.
0.3 mg/kg as a slow iv Do not give more than 2 doses in
Diazepam 10 mg/2ml amp push over 2 min or 24 hour
0.5mg/kg intra-rectally.
18 mg/kg loading dose
Phenytoin 100mg/2ml amp then 5mg/kg per day for
48 hours
0.6mg/kg
Furosemide 10 mg/ml amp
40 mg (adult dose)

500 mg/kilo Diluted to 10% before use.
5ml/kg of 10% thru Dilute 1 volume of 50% dextrose
peripheral line followed with 4 volumes sterile water to get
50% Dextrose
by 5ml/kg/hour of 10% 10% dextrose
dextrose or 10ml/kg/hour
of 5% solution
In children <12 months Assess hydration after the first
old give 30ml/kg bw in 1h, dose and repeat 30ml/kg if the
then 70ml/kg bw over the pulse is still week.
Ringer’s next 5h
250ml, 500 ml
Lactate Monitor urine output to assess
and 1 litre bot.
Solution Children ≥12 months old, kidney function.
give 30ml/kg over
30mins, then 70ml/kg
over next 2½h.
Isotonic Alternate IVF if Ringer’s Lactate
Saline 1 Liter bottle solution is not available
Solution
III Treatment of Confirmed Malaria
Malaria infection has a broad range of manifestations. It can be an asymptomatic infection in

one end to an infection with severe manifestations and multi-organ failure on the other end.
Confirmatory test and clinical manifestations must be taken into consideration in order to
manage the case properly. Deterioration can be rapid and death can come from the infection
or its complications.
Directory for treatment regimen of malaria based on the revised treatment protocol is shown
in Table 3.1l. Use the table by looking at the diagnosis and condition of the patient in the first
column then follow the row to the right where the diagnosis is, follow the row for the treatment
regimen then go to the page where the dosing table is located. The tables list the number of
tablets by weight or by age group.
Keep in mind that the treatment of malaria consists of schizontocidal (curative) plus
gametocidal (transmission blocker) or anti-relapse medicines (tissue schizontocidal).
Gametocytes do not produce symptoms but they should be treated to block transmission.
Hypnozoites (Pv and Po) reactivates several months later and continue transmission.
Fourteen (14) day course of primaquine will kill the hypnozoites in the liver and prevent
relapse. Primaquine is contraindicated to pregnant mothers and children below 1 year old
because of the unknown status of glucose–6–phosphate dehydrogenase (G6PD) enzyme
which is anti-oxidant. Primaquine can cause hemolysis among people with G6PD enzyme
deficiency. Primaquine is used as anti-gametocte (single dose) for Pf and as anti-relapse (14
day course) for Pv and Po.

Tourist and Students from Malaria Endemic Countries
Visitors and students from malaria endemic countries may be found positive during
screening. Close monitoring of response to treatment is needed because they may be
carrying different strain of parasite that may not be susceptible to the medicines provided by
the program.
Table 3.11 Malaria Treatment Directory

Condition of Directory Dosing
Diagnosis Treatment Regimen
Patient Table
Pf AL + Table 3.12 (pp 48) &
Pm PQ anti-gametocyte (1 day) Table 3.13 (pp 49)
Uncomplicated
Pv AL+ Table 3.12 (pp 48) &
Po PQ anti-relapse (14 days) Table 3.15 (pp 51)
AL + Table 3.12 (pp 48) &
Pf+Pm
PQ anti-gametocyte (1 day) Table 3.13 (pp 49)
Uncomplicated Pf +Pv
mixed infection Pf+Po Table 3.12 (pp 48) &
AL +
Pv+Pm
PQ anti-relapse (14 days) Table 3.15 (pp 51)
Pv+Po
Pm+Po
Pf Artesunate IV for 24 hours then Table 3.16 (pp 52)
A-L+ then
PQ anti-gametocyte (1 day) Table 3.12 (pp 48) &
Table 3.13 (pp 49)
Pv Artesunate IV for 24 hours then Table 3.16 (pp 52)
A-L+ PQ anti-relapse (14 days) then
Table 3.12 (pp 48) &
Table 3.15 (pp 51)
Severe Malaria Pv QN + antibiotic + PQ anti- Table 3.18 (pp 53) &
relapse (14 days) Table 3.15 (pp 51)
Pre- referral Children -Artesunate Table 3.17 (pp 52)
suppository Table 3.17 (pp 52)
Adults - Artesunate im/iv
Treatment Failure Pf
Children< 8 Pf QN + Clindamycin + PQ anti- Table 3.18 (pp 53) &
years old gametocyte (1 day) Table 3.13 (pp 49)
Adults Pf QN + antibiotic + PQ anti- Table 3.18 (pp 53) &
gametocyte (14 days) Table 3.13 (pp 49)

Treatment Failure Pv
Children< 8 Pv QN+ Clindamycin+ PQ anti Table 3.18 (pp 53) &
years old relapse (14 days) Table 3.15 (pp 51)
Adults Pv QN + antibiotic+ PQ anti- Table 3.18 (pp 53)&
relapse (14 days) Table 3.15 (pp 51)
Relapse Pv or Po CQ + PQ anti-relapse (14 days) Table 3.14 (pp 50) &
Pv or Po Table 3.15 ( pp 51)
Pregnant
Pf uncomplicated
Pf severe QN + Clindamycin (adult dose) Table 3.18( pp 53)
Mixed
First Trimester
Pv
Pm CQ Table 3.14 (pp 50)
Po
Pf uncomplicated
Pf severe AL + Clindamycin (adult dose) Table 3.12 (pp 48)
Second and Mixed
Third Trimester Pv,
Pm AL Table 3.12 ( pp 48)
Po
Two weeks Pf
PQ anti-gametocyte Table 3.10 (pp 44)
Postpartum- Pm
(completing Pv
treatment of Po PQ anti relapse× 14 days Table 3.15 (pp 51)
malaria while Mixed
pregnant)
Pf AL + Clindamycin +PQ anti- Table 3.12 (pp 48) &
gametocyte Table 3.13 ( pp 49)
Pv CQ + PQ anti-relapse× 14 days Table 3.14 (pp 50) &
Table 3.15 ( pp 51)
Lactating Pm AL + PQ anti-gametocyte (1 Table 3.12 (pp 48) &
mothers day) Table 3.13 (pp 49)
Po AL + PQ anti-relapse (14 days) Table 3.12 (pp 48) &
Table 3.15 (pp 51)
Mixed AL + Clindamycin PQ anti- Table 3.12 (pp 48) &
relapse (14 days) Table 3.15 ( pp 51)

Table 3.12
Dosing Schedule of Artemeter-Lumefantrine (AL)
Preparation: Blister packs of 6×1, 6×2, 6×3, and 6×4 tablets
Use body weight to administer the correct dose
(Use age If weight cannot be taken but observe caution for under dosing
among overweight and over dosing for underweight individuals.)
Body 15 - <25 25 -
5 - <15 kg ≥35 kg
weight(kg) kg <35kg
(6 mos.– 3
Age (4- 8 y.o.) (9-13 y.o.) If (>13y.o.)
y.o.)
Day 1
1 tab 2 tabs 3 tabs 4 tabs
Initial Dose
8 hrs after 1 tab 2 tabs 3 tabs 4 tabs
Day 2
am 1 tab 2 tabs 3 tabs 4 tabs
pm 1 tab 2 tabs 3 tabs 4 tabs
Day 3 1 tab 2 tabs 3 tabs 4 tabs

am
pm 1 tab 2 tabs 3 tabs 4 tabs
Drug information
Artemether is lipophilic and fairly readily absorbed from gastro-intestinal tract. It is 95 to

99% protein bound. It is metabolized by the liver and excreted through feces and urine.
It has a half- life of 2 hours. Lumefantrine is highly lipophilic and readily absorbed if
taken with fatty meal. It has a half-life of 3 days. Combination of medicine with short and
long half-life delay development o drug résistance. They are active against blood forms
of malaria including young gametocytes.
AL is well tolerated. Reported side effects include nausea, dizziness and headache.

Table 3.13
Dosing Schedule of Primaquine (PQ) as Anti-Gametocyte
Preparation: Tablets of 7.5 mg and 15 mg base
(Single Dose on Day 1)
Use body weight in kilogram (kg) to compute the right dose.

Dose per kilo is 0.25 mg base given single dose on Day 1.
Computation by weight:
Let
A= Body weight B= 0.25 mg
C= 15 mg base per tablet D= dose in tablets of 15 mg base
Note: if 7.5 mg tab is available change C and D to 7.5 mg
Then D=(A×B)÷C
Use age if weight cannot be taken but observe caution for under dosing among
overweight and over dosing for underweight individuals.
< 1 y.o. 1-3 y.o. 4-6 y.o. 7-11 y.o. > 12 y.o
(10-15 (16 – 30 kgs) (31-60 (61 -90
kgs) kgs) kgs)
7.5 mg contra-
½ 1 2 3
base/tab indicated
15 mg contra-
¼ ½ 1 1½
base/tab indicated
Drug Information
Primaquine is an 8-aminoquinoline derivative with a potent action against intrahepatic

forms of all human parasites. It has gametocidal effect against all species. It is readily
absorbed when taken orally with a peak plasma concentration of 1 -3 hours and a half
life of about 5 hours. Blood and urine should be examined periodically for evidence of
hemolysis. Patients should be warned to stop medicine if they notice darkening of urine
or if they develop abdominal pain or pallor. Tablets must be kept in well closed
containers protected from light.

Table 3.14
Dosing Schedule for Chloroquine (CQ)
Preparation: 150 mg base per tablet
Use body weight in kilogram (kg) to compute the right dose.

Dose in Day 1 and Day 2 is 10 mg/kg
Dose in Day 3 is 5 mg/kg
Let
A= Body weight B= 10 mg
C= 150 mg base per tablet D= dose in tablets of 150 mg base
Note: Change B to 5 mg if computing for Day 3 dose
Then D=(A×B)÷C
AGE
0-11 1-3 y.o. 4-6 y.o. 7-11 12-15 > 16
Day of Treatment months y.o. y.o. y.o.
Day 1 1/2 1 1½ 2 3 4
Day 2 ½ 1 1½ 2 3 4
Day 3 1/2 1/2 1 1 1½ 2
Drug Information
Chloroquine is active against blood forms of malaria except gametocytes. It is

completely absorbed after oral administration and widely distributed in the body. It is
metabolised in the lived and eliminated slowly from the body, 55% eliminated via the
kidney. Taking the drug with food helps avoid gastrointestinal intolerance.

Table 3.15
Dosing Schedule for Primaquine (PQ) Anti-relapse Treatment
(14 daily doses)
Preparation: 7.5 mg and 15 mg base per tablet
Use body weight in kgs to compute the right dose.

Dose per kilo is 0.25 mg base/day for 14 days starting on Day 1.
Let
A= Body weight(kg) B= 0.25 mg dose per kg
C= 15 mg tab (base) D= dose (in tablet of 15 mg base)
Then
D= (A×B) ÷ C
Use age as basis if weight cannot be taken but observe caution for under dosing
among overweight and over dosing for underweight individuals.
Age 0-11 1-6 >7 years (31-60 kg) (61-90 kg)

months years (16-30 kg)
(10-15 kg)
Number 7.5 mg contra- ½ 1 2 3
of base/ta indicated
tablets b
per day 15 mg Contra- ¼ ½ 1 1½
for 14 base/ta indicated
days b
Drug Information
Primaquine is an 8-aminoquinoline derivative with a potent action against intrahepatic

forms of all human parasites. It has gametocidal effect against all species. It is readily
absorbed when taken orally with a peak plasma concentration of 1 -3 hours and a half-
life of about 5 hours. Blood and urine should be examined periodically for evidence of
hemolysis. Patients should be warned to stop medicine if they notice darkening of urine
or if they develop abdominal pain or pallor. Tablets must be kept in well closed
containers protected from light.

Table 3.16
Dosing Schedule for Artesunate IV
Preparation: Artesunate 60 mg vial
for reconstitution with accompanying sodium bicarbonate and then saline
solution
Body Dose 2 Dose 3 Shift to Oral
Dose per kg Dose 1
Weight (12 (24 A-L + PQ after Dose
body weight (0 hour)
(kg) hour) hour) 3
<20 3.0 mg/kg See Table 3.9 for AL
>20 2.4 mg/kg dosing and Table
25 2.4 mg/kg 1 vial 1 vial 1 vial 3.10 for PQ dosing
25 -50 2.4 mg/kg 2 vials 2 vials 2 vials
51 –75 2.4 mg/kg 3 vials 3 vials 3 vials
75-100 2.4 mg/kg 4 vials 4 vials 4 vials
Drug Information
Artesunate kills young circulating ring parasites.

The drug is well tolerated with no local or systemic adverse effects.
Table 3.17
Dosing Schedule for Artesunate Suppository
Preparation: 50, 200, and 400 mg suppository
Weight (kg) Artesunate Dose
< 40 10 mg /kg
(use appropriate number of 50 or 200 mg suppository )
40 – 59 400 mg (1 × 400 mg suppository)
60 – 80 800 mg (2 × 400 mg suppository)
> 80 1200 mg (3 × 400 mg suppository)
Artesunate suppository should be stored in refrigerator to make it ready for use. Chill
suppository before use if there is no refrigerator for easy insertion into the rectum.

Table 3.18
Dosing Computation for Quinine Plus Antibiotic
Preparation of Quinine Sulfate : 300 mg and 600 mg tablet
Age Group Quinine Plus anyone of the antibiotics below

Sulfate
(300 or 600
mg/tablet) Doxycycline Tetracycline Clindamycin
100 mg /cap 250 & 500 150 & 300 mg
mg/cap cap
150 mg/ml amp
10 mg 3 mg/kg bw 250 mg4 10 mg/kg bw
Adults and salt/kg per once a day times a day twice a day
Children >8 dose every (OD) for 7 (QID) for 7 (BID) for 7 days
years old 8 hours for days days
7 days
10 mg Contra- Contra- 10 mg/kg bw
Children < 8 salt/kg per indicated indicated twice a day
years old dose every (BID) for 7 days
8 hours for
7 days
Drug Information
Quinine is blood schizontocidal drug. It is rapidly absorbed when taken orally with
peak plasma concentration of 1-3 hours. Its half- life is 10 hours. It is metabolised in
the liver and excreted in the urine. Quinine may promote insulin secretion and induce
hypoglycaemia. Quinine injection must be protected from light.
Possible adverse drug reaction: hypoglycemia, arrhythmia
8.2 Complicated Malaria
I Pathophysiology
Red blood cells parasitized by Pf have knobs on the surface. They are sticky and adhere to
endothelium of internal organs blocking circulation causing hypoxia. Another cause of
hypoxia is anaemia produced by repeated destruction of RBCs as a result of parasite
reproduction inside RBC. Plasmodium vivax infection can also produce severe malaria
occasionally.

II Clinical features of severe malaria include one or more of the following:
 impaired consciousness (including unrousable coma)
 prostration, i.e. generalized weakness so that the patient is unable to sit, stand or
walk without assistance;
 multiple convulsions (more than two episodes within 24h)
 deep breathing and respiratory distress (acidotic breathing)
 acute pulmonary edema and acute respiratory distress syndrome
 circulatory collapse or shock (systolic blood pressure < 80mm Hg in adults and <
50mm Hg in children)
 acute kidney injury
 clinical jaundice plus evidence of other vital organ dysfunction
 abnormal bleeding (disseminated intravascular coagulation)
III Laboratory and other findings

 hypoglycemia (< 2.2mmol/l or < 40mg/dl)
 metabolic acidosis (plasma bicarbonate < 15mmol/l)
 severe normocytic anemia (hemoglobin < 5g/dl or hematocrit of< 15% in children;
<7g/dl, or hematocrit< 20% in adults)
 hemoglobinuria
 hyperlactataemia (lactate > 5mmol/l)
 renal impairment (serum creatinine> 265μmol/l) and
 pulmonary edema (radiological).
IV Management of complications
Table 3.19 Management of Malaria Complications

Hypoglycemia
-Blood glucose of less than 0.2mmol/l (40mg/dl)
Pathophysiology Manifestations Management
- poor oral intake due Conscious patients -Give 50ml of 50% dextrose
to vomiting or because -anxiety, sweating, dilatation of the (25 g) diluted with 100ml of
of high insulin level pupils, breathlessness, a feeling of any infusion fluid and infused
induced by quinine coldness, tachycardia and light- over 3–5min.
therapy headedness. -Follow with an intravenous
-reduced hepatic infusion of 200– 500mg/kg per
gluconeogenesis Unconscious patients hour of 5% or 10% dextrose.
-increased peripheral -convulsions and extensor posturing -Continue to monitor blood
utilization of glucose glucose levels because
hypoglycaemia may recur
even after treatment with
intravenous dextrose

Acute Kidney Injury
- raised serum creatinine(> 265μmol/L) and blood urea concentrations
-part of multi-organ Oliguria -Infuse isotonic saline to
dysfunction in correct hypovolemia
fulminant infections -Peritoneal dialysis or
- acute tubular necrosis hemodialysis if infusion fails
-hypovolemia to correct oliguria
Anemia
- hemoglobin of < 5g/dl or hematocrit of < 15% in children
- hemoglobin of <7g/dl, or hematocrit< 20% in adults
-destruction of Pallor -transfusion of screened,
parasitized RBC compatible packed RBC or
fresh whole blood
- include the volume of
transfused cells or blood in
calculating fluid balance to
avoid fluid overload
Pulmonary Edema
-Radiologic evidence of pulmonary edema resembling acute respiratory distress syndrome
(ARDS)
-Increased pulmonary -Increase respiratory rate -Keep the patient upright
capillary permeability -cough - Give high concentration of
-Fluid overload -difficulty of breathing oxygen
-IV diuretic, such as
furosemide at 0.6mg/kg (adult
dose, 40mg) increase dose if
necessary
-Venesection if there is fluid
overload and stop IV fluid
Continue on next page
Continuation of Tale 3.19
Metabolic Acidosis
-Low plasma bicarbonate
-Microvascular -Labored, rapid, deep breathing -Improve oxygenation by
obstruction by (Kussmaul’s breathing) clearing the airway,
sequestered increasing the concentration
parasitized of inspired oxygen
erythrocytes - Isotonic fluid (0.9% saline)
-Hypovolemic shock by slow intravenous infusion
to restore the circulating
volume
-Monitor blood pressure, urine
volume (every hour) and
jugular venous pressure
Shock
-Systolic blood pressure less than 80 mm Hg
-inadequate intake -Cool hands and/or feet, capillary -Correct hypovolemia with
-vomiting refilling time > 2seconds(include maintenance fluids at 3–
dengue table) 4ml/kg per hour

-Take blood for culture, and
start the patient on
appropriate broad-spectrum
antibiotics immediately
Manifestations of compensated and hypotensive shock
PARAMETERS COMPENSATED HYPOTENSIVE
Sensorium Clear and lucid Decreased level of
consciousness
Capillary refill Prolonged (>2 secs.) Very prolonged plus mottled
skin
Extremities Cool peripheries Cold and clammy
Peripheral pulse Weak and thread Feeble or absent
Heart rate Tachycardia Severe tachycardia with
bradycardia in late shock
Blood pressure Normal systolic pressure but Narrowed pulse pressure
rising diastolic pressure; (<20 mmHg) or un-recordable
Narrowing pulse pressure blood pressure
Postural hypotension
Respiratory rate Tachypnea Hyperpnea or Kussmaul’s
breathing
Cerebral Malaria
-Microvascular -fever (37.5–41°C), followed by -Parenteral anti-malaria
obstruction by failure to eat or drink or anyone of (Artesunate or Quinine) for 24
sequestered the following: hours or more.
parasitized -Vomiting, cough, diarrhea(less -Manage seizure with
erythrocytes common) Diazepam
-Prostration -Correct anemia, bleeding,
-Coma hypovolemia, hypoglycaemia-
-Seizure -Look out for other central
-Abnormal motor posturing nervous system infections
and manage accordingly
Abnormal Bleeding
Disseminated intravascular Coagulation
Bleeding gums Transfuse fresh blood, clotting
Epistaxis factors or platelets as required
Petechiae Give Vitamin K, 10mg, by slow
Subconjunctival haemorrhage intravenous injection.
Hematemesis - blocker (e.g. ranitidine)
Melena
Dehydration and Electrolyte imbalance

-Raised blood urea (> 6.5mmol/l; > 36.0mg/dl)
-Urinalysis reveals a high specific gravity, the presence of ketones, low urinary sodium and
normal urinary sediment
Poor fluid intake Decreased skin turgor Rapid IV rehydration followed
Vomiting Signs of decreased peripheral by oral rehydration therapy
Diarrhea perfusion with Ringer’s lactate solution
Hypovolemia Oliguria
For Infants-30ml/kg bw in 1h,
then 70ml/kg bw over the next
5h

For children ≥12 months old,
give 30ml/kg over 30mins,
then 70ml/kg over next 2½h
Monitor urine output for

adequacy of fluid infusion and
respiratory rate for signs of
fluid overload.
Hemoglobinuria
Intravascular Dark urine Transfuse screened fresh
haemolysis and blood if necessary
hemoglobinuria Dialysis if oliguria develops
precipitated by and blood urea and serum
primaquine or other creatinine levels increase
oxidant drugs in
patients with G6PD
deficiency
8.3 Monitoring Response to Treatment
Drug resistance can develop to any anti-malaria regimen. All cases should be monitored by
taking blood smear on Day 3, 7, 14, 21 and 28. Monitoring is extended monthly for 6 month
for cases of P vivax and P ovale to detect relapse early. If weekly follow up smear cannot be
followed weekly the least follow up smear can be on Day 3, 7 and 28. Responses to treatment
are summarized in Table 3.16. It is based on clinical manifestations and blood smear result. It
is showing the importance of doing parasite count in every malaria positive blood smear.
Management of treatment failure is already discussed early in this chapter.
Table 3.20 Treatment Response
Response Criteria
Absence of parasitemia on Day 28 irrespective of temperature, without
Adequate Clinical and
meeting any of the criteria of Early Treatment Failure or Late Clinical
Parasitological
Failure or Late Parasitological Failure.
Response (ACPR)
Development of danger signs or severe malaria on Day 1, Day 2 or Day 3

in the presence of parasitemia; OR
Parasitemia on Day 2 higher than Day 0 count irrespective of axillary
Early Treatment Failure
temperature; OR
(ETF)
Parasitemia on Day 3 with axillary temperature ≥ 37.5 °C; OR
Parasitemia on Day 3 ≥ 25% of count on Day 0.
Development of danger signs or severe malaria on any day from Day 4 to

Late Clinical Failure
Day 28 in the presence of parasitemia, without previously meeting any of
(LCF)
the criteria of Early Treatment Failure; OR
Presence of parasitemia and axillary temperature ≥ 37.5oC (or history of
fever) on any day from Day 4 to Day 28, without previously meeting any of
the criteria of ETF.
Presence of parasitemia on any of the scheduled return on Day 7, Day 14,

Late Parasitological
Day 21 or Day 28, and axillary temperature < 37.5 oC without previously
Failure (LPF)
meeting any of the criteria of ETF.

9 Malaria Vector Control
Policy Direction
Universal coverage of vector control measures will also be ensured. Use of insecticide treated
nets (ITN), particularly the more cost-effective long lasting insecticidal nets (LLIN) is the main
vector control measure. Indoor residual spraying (IRS) with insecticide shall be adopted in areas
where the use of net is not culturally acceptable, displaced population and epidemic situations.
IRS will also be done with guidance from the results of epidemic and foci investigations.
Mosquitoes spend half of their life in water. Vector control for malaria can be against the
aquatic stages of the mosquito or against the adult (Table 3.21). The choice will depend upon
the desired effect, cost and bionomics of the vector. LLIN and IRS are ideal because they are
selective of adult female mosquitoes and have long duration of effectiveness. LLIN is the
primary vector control method because it kills the vector and acts as barriers to prevent
mosquito bite. Reports showed that mosquitoes were able to bite before they are killed by the
insecticides deposited in the wall by IRS i.e. mosquitoes were able to transmit the parasite
before they are killed.
Malaria vector control relies heavily on chemical insecticide. Only insecticides that
pass WHOPES must be used for vector control. The major criteria used in the choice
of insecticides focus on its safety as indicated by the degree of hazard its use can
impose. Basically insecticides classified as being unlikely to be hazardous are
preferred to insecticides which are classified as being mildly or moderately hazardous.
Other indicators for safety include the lethal dose 50 and the neurologic and
dermatological toxicity indicators. Preferences for insecticides at the lower end of the
spectrum is the norm. The second criteria is of course efficacy manifested as knock-
down or kill-rate to the targeted insect carrier, Safety precaution must be observed in
handling insecticide at all times.
Since LLIN distribution and use and IRS are used as complimentary measures, to
avoid over-saturation with the insecticide, a different insecticide molecule is used for
LLINs and for in-door residual spraying.
The program provides free LLIN in barangays stratified under active and residual non-active.
It can also be provided to cleared barangays that convert to active as a result of re-introduction
of malaria after a thorough case-foci investigation (see Table 3.2).
Reduction of breeding habitat if few and small in size can complement IRS and LLIN.
Management of breeding site will be the vector control of choice when the parasite is already
eliminated in a province.

Table 3.21 Purpose and Types of Vector Control
Purpose Type of Control
Reduction of longevity of vector population IRS, LLIN
Reduction of vector densities IRS and LLIN
Environmental modification and manipulation
Reduction of breeding habitats
Chemical and biological larvicides
Malaria vector control relies heavily on chemical insecticide. Only insecticides that pass
WHOPES must be use for vector control. Safety precaution must be observed in handling
insecticide at all times.
Vector Control in Malaria Cleared Areas
Malaria cleared areas can still have vector control if they share borders with active foci or there
are population movement (vulnerability) like evacuation centers, housing in
development/mining sites. Scaling down of vector control activities in cleared foci is necessary
to lessen environmental effects of insecticides. The program will continue to promote use of
nets for cleared barangay(s)/sitio(s). Integrated vector management (IVM) will have greater
role in malaria cleared areas as it will be targeting a wider range of vector borne diseases.
9.1 Long Lasting Insecticidal Net (LLIN)
 Objective of LLIN is to kill the mosquitoes thereby reduce the mosquito population.
 It is the primary malaria vector control of the program.
 Target vector mosquitoes of LLIN are those feeding indoor and biting late evening to
early morning
 More than 80% of population must be sleeping inside the LLIN every night to provide
community protection and reduction of incidence.
 NMCEP distributes free LLIN in Barangays/sitios stratified under active foci. All (100%)
household must have LLIN. One free LLIN is distributed for every 2 persons in the
household
 Distribution comes with instructions to sleep inside the mosquito net every night and
proper care and washing of LLIN. Nets must be kept intact. Owners are encouraged
to repair torn nets or those with holes.
 Insecticide in LLIN last for 2 to 3 years. Replacements are made depending on the
type of LLIN.

Procedure for LLIN Distribution
Table 3.22 Procedure for LLIN Distribution

Step Activity Remarks
1 Compute for LLIN Requirement Net to
A = Required LLIN population
B= Population of active foci barangays/sitios ÷ 2 ratio is 1:2
C= Population of residual non-active barangays/sitios ÷ 2
D= Pop of malaria cleared barangays/sitios in receptive and
vulnerable ÷ 2
E= 10% allowance
F= Single (180x100x150 cm) = 70%
G= Family (180x160x150 cm) = 30%
A(required LLIN)=(B+C+D) × 1.1
Size Distribution
F(Single) = A×0.7
G(Family) = A× 0.3
2 Make a request for LLIN and send to Regional Office through
PHO
3 Wait for the delivery of LLIN
4 Prepare activities for mass LLIN distribution:
Lectures
Distribution of information materials
Request the presence of LCE’s and other influential people
Request target community to submit list of households with
name and age of household members
5 Mobilize Community for mass distribution of LLIN
6 Gather the community members on scheduled date
7 Deliver the speeches and other presentations
8 Distribute LLIN with personal messages “Sleep inside
mosquito net every night” and “use mild soap in washing the
mosquito net”.
9 Ask the recipient for signature or thumb mark in the LLIN
distribution form
10 Prepare summary report of distribution and send copies to
PHO and RO
11 Revisit the community after two weeks and make a random
interview of 25 households. Ask how many people slept inside
the LLIN “last night” and how many did not. Record the result
and make a report.
12 Revisit the community at least quarterly, do the random
interview and remind them to “use mosquito net every
night”.
13 Keep a record of every monitoring visit to gauge the proportion
of LLIN usage.

9.2 Indoor Residual Spraying (IRS)
 Objective of IRS is to shorten the lifespan of adult mosquitoes, reduce mosquito

population density and reduce man and mosquito contact
 Applied in barangays/sitios where sleeping inside mosquito net is not culturally

acceptable and during epidemics.
 Target mosquito vectors that rests before and after a blood meal
 Supplementary vector control method when LLIN fails or until LLIN distribution
coverage exceeds 85%
 More than 85% of houses must be sprayed to provide community protection
 Residual insecticide is effective when properly applied to wall surfaces.
 IRS deposits insecticide to the walls in the form of dust. Mosquitoes coming into
contact to the sprayed wall are exposed to this powder and are carried in their hairs.
The insecticide is absorbed and kills the mosquito later.
 Quality of spraying is important to be effective. Insecticide must be sprayed evenly on

the surface of the wall. Proper spraying technique, appropriate spray can and right
insecticide formulation are required for uniform distribution of sprayed insecticide.
 IRS must be applied by trained spray men. Participants perfect the technique through
practice on spray board. They also learn the operation and proper maintenance of
spray can, safe handling of insecticide and first aid for insecticide poisoning. One day
refresher training for spray men must be conducted before deployment.
 The appropriate spray cans for IRS are those fitted with T-Jet 8002 nozzles (Fig 3.4).
The discharge is fan shape with a discharge rate of 760 ml per minute at 55 to 45 psi
operating pressure. Spray cans without these specifications will not be able to deliver
the required quality of IRS and must not be use.
 Spraying a barangay must be finished within ten days or less. All houses (100%) in the
target community must be sprayed to provide community protection. It will not be
effective if less than 85 % of houses are sprayed.
 All surfaces inside the house that can be a resting place of mosquito must be sprayed.
The sprayable surfaces are the inside walls, underneath the tables, chairs, cabinet,
eaves, ceiling and other surfaces where mosquito can rest. Children’s toys and graven
images must not be sprayed. Outside walls not exposed to sun/rain can also be
sprayed. Other structures where people sit/rest during the night must be sprayed
including animal sheds.
 The procedure in IRS is detailed in Annex 13.

Fig.3.4 Spray can (left) and the fan shape discharge (right) of T-Jet 8002 nozzle
tip.
 Insecticides suitable for IRS are listed in Table 3.23. All insecticide for IRS must be
WHOPES recommended. Safety must be observed at all times while handling
insecticide. Spray men must be provided with personal protective equipment namely
wide brim hat, goggles, face mask, cover all suit, gloves and rubber boots.
Table 3.23 List of WHOPES Approved Insecticides for IRS

Insecticide Dosage (gm/m2) Residual Effect Hazard
(months) Classification*
Pyrethroids
Alphacypermethrin 5% WP 0.02 – 0.03 4–6 II
Bifenthrin 10%WP 0.025 – 0.05 3–6 II
Cyfluthrin 10%WP 0.020 – 0.05 3–6 II
Detamethrin 2.5%WP & 5% 0.02 – 0.025 3-6 II
WP
Unlikely to present
Etofenprox 0.1-0.3 3-6 acute hazard in
normal use
Lambdacyhalothrin 10%WP 0.025 – 0.05 3-6 II
Carbamates
Bendiocarb 80%WP 0.1 – 0.4 2–6 II
Propoxur 50 %WP 1–2 3–6 II
Organophoshate
Malathion 50% WP 1.1 – 2.2 2–3 III
Fenitrothion 40% WP and 2.0 3–6 II
50% WP
Primiphos methyl WP 1.0 – 2.0 2–3 III
*WHO Hazard Classification: la -extremely hazardous, lb -highly hazardous, II - Moderately
hazardous, III - slightly hazardous9Ref)

9.3 Integrated vector management (IVM)
 Defined as "a rational decision-making process for the optimal use of resources for
vector control" and includes five key elements namely:
1. evidence-based decision-making,
2. integrated approaches
3. collaboration within the health sector and with other sectors
4. advocacy, social mobilization, and legislation, and
5. capacity-building
 Involvement and cooperation of all stakeholders are necessary for successful vector
control. The previous vertical set-up of the program had not carried the program to the
present level. The accelerated achievement of the target was achieved on a
background of a highly devolved health system. It has a semblance of IVM. There is
evidence-based decision making (stratification, testing before treatment), collaboration
with health sector and other sectors (Central Office, Regional offices, LGUs, PSFI,
WHO, NCIP etc,), capacity building, integrated approaches (LLIN+IEC+ACD+case
management), and advocacy.
 In the near future the LGUs will be the major player to sustain their malaria free status,
integrating them with other vector borne diseases program and with the general health
services is the most rational thing since the same individual performs all vector borne
disease control tasks.
 Adjunct vector control methods are listed in Annex 13.

10 Health Promotion
Policy Direction
Health Promotion will be enhanced through the delivery of key messages focused to
each group of stakeholders and according to the stratification category of areas.
I. Introduction
The national strategic plan for the elimination and control of malaria highlights the strategy
(Strategy 1.4) on increasing the demand for effective malaria interventions and services such
as vector control interventions, early diagnosis, prompt case management and treatment
among the endemic population. It aims to improve knowledge and awareness of community
members about malaria and malaria risk, improve their behaviors in seeking prompt and timely
services from appropriate sources, comply with diagnosis and treatment protocols, and apply
appropriate personal practices to prevent them from getting infected in the first place and from
further transmitting the infection via mosquito vectors to other community members.
The focus of health promotion will be on expanding the implementation of behavior change
interventions (e.g. CoMBI approach) to a wider range of LGUs and communities. The health
promotion strategy will take note of the specific information needs of identified vulnerable
groups and the dissemination process, tailoring it to the characteristics and needs of each
group. Support must also be provided to ensure continuity of IEC in the Zero Indigenous Case
and Malaria Free Provinces to keep community members alert to the possible re-introduction
of the disease.
The National Center for Health Promotion (NCHP) of the Department of Health (DOH) is in
the process of updating the National Policy on Health Promotion which will harmonize the
various approaches on awareness raising and behavior change promotion. The “disease free
zone initiative” promulgated in the health sector reform agenda, includes malaria-endemic
areas as target for intensive campaign to eliminate the disease as a public health threat. It
calls for the enhancement of health promotion activities coupled with strengthened
surveillance activities to ensure that the targets for disease prevention, control and elimination
are attained.
II. Objectives
This Chapter is primarily designed to guide local health care managers and service providers
in the design and implementation of their respective health promotion initiatives to achieve
communication objectives specific for influencing behavior that will result in further decline and
eventual elimination of malaria. Specifically, it aims to:
(1) orient health staff on the importance, guiding principles, key strategies and appropriate
health promotion activities;
(2) guide health managers and local officials in formulating their respective local health
promotion plan; and

(3) provide a list of key messages and recommended channels/media as basis in
developing local Information, Education and Communication (lEC) materials and other
promotional supplements.
III. Policy Directions
Health promotion efforts will be geared towards the following directions:
Intensification of health promotion activities to support the elimination of malaria as a public

health threat;
(1) Development and focusing of key messages to meet the specific needs and situations
of localities at varying stages towards malaria elimination;
(2) Adaptation/localization of IEC approaches and initiatives to influence health practices
and health seeking behavior among vulnerable and at risk groups; and
(3) Strengthening local health capacities to plan and undertake appropriate health
promotion activities to support transition towards elimination of the disease.
IV. Guiding Principles
There are 3 basic principles to be observed in health promotion:
(1) Health promotion must involve the population as a whole in the context of their
everyday life, rather than focusing on people at risk from malaria;
(2) Health promotion must be directed towards actions on the determinants of malaria
transmission. This requires close cooperation among different sectors beyond health
care, reflecting the diversity of conditions which influence health; and
(3) Health promotion must combine diverse but complementary approaches including
communications, education, legislation, fiscal measures, organizational change,
community development, and spontaneous local activities against malaria.
V. Key Strategies
Health Promotion shall follow the five areas for action that correspond to the key strategies.
A. Building Healthy Public Policy
Building healthy public policy activities target local government officials as well as policy
makers at the national, regional and local levels. It requires advocacy for the development and
issuance of the following policy instruments to support health: (i) laws, local resolutions and
ordinances; (ii) executive orders; (iii) memorandum circulars; (iv) administrative orders; and
(v) memorandum of agreement. The prevention, control and elimination of malaria require
healthy public policy efforts in the following areas:

Areas for Healthy Public Policy Efforts
In Support of the Prevention, Control and Elimination of Malaria
(1) hiring and/or absorption of malaria personnel

(2) enrollment of households to Philippine Health Insurance (Phil-Health)
(3) allocation of budget to support local malaria operations (e.g. salary of personnel,
logistics, orientation/training of health providers, participation in diagnostic quality
assurance system, health promotion activities, incentives for barangay health workers,
etc.)
(4) provision of logistics requirements: insecticide treated nets (ITNs), reagents,
laboratory supplies, medicines and supplies for supportive treatment
(5) installation or networking of laboratory and diagnostic facilities including quality
assurance (microscopy services) for both public and private facilities
(6) installation and maintenance of continuous surveillance, particularly in tracking
malaria suspects
(7) establishment of system of close guarding and prompt reporting of
possible entry of malaria infected persons in areas which have been declared
malaria-free
(8) setting up of regulatory mechanism for the over-the-counter sale of antimalarial drugs
B. Creating A Supportive Environment
Creating a supportive environment involves increasing access to health services both, through
improvement of physical location and set-up, as well as ensuring client-centered service
provision. It also requires the creation of coalitions, networks, and inter-agency committees
to multiply the number of people promoting particular health actions. To achieve this, the
following activities must be undertaken:
Activities In Creating A Supportive Environment

for the Prevention, Control and Elimination of Malaria
(1) promotion of the availability of quality diagnostic and treatment services for malaria and
where these can be availed at (e.g. barangay malaria microscopy centers in strategic areas,
etc.).
(2) mobilization of private facilities to provide malaria prevention and control services.
(3) mobilization of local government units (LGUs) to devise distribution schemes for ITNs for
hard to reach areas and among vulnerable segments of the population.
(4) establishment of network among contiguous/nearby health facilities to offer complete
intervention measures to malaria patients (e.g. referral to a nearby laboratory facility, etc.).
(5) promotion of the adoption of Directly Observed Treatment (DOT) especially in hard to reach
areas where it may be difficult for malaria patients to be going back and forth to complete
their treatment.
C. Strengthening Community Action
Health promotion works through concrete and effective community action in identifying
priorities, making decisions, planning strategies and implementing them to reduce malaria
cases and prevent re-introduction of infection.

Activities In Strengthening Community Action
for the Prevention, Control and Elimination of Malaria
(1) establishment of system of malaria treatment partner

(2) campaign for volunteers to participate in vector control activities especially in
indoor residual spraying and border operations
(3) creation of malaria task forces (community-based network) that will develop and
implement community-based malaria prevention program
(4) health education activities such as health forum during barangay assembly,
community leaders’ assembly, etc.
(5) establishment and maintenance of community surveillance system
D. Developing Personal Skills
Developing personal skills is done through provision of information and education on health
and enhancement of people’s life skills using all possible channels, opportunities and
venues (e.g. home, school, workplace, etc.) by various relevant institutions or stakeholders
with the required expertise.
Personal Skills Development
in Support to the Prevention, Control and Elimination of Malaria
(1) conduct of interpersonal communication between a health care provider in the

facility with the malaria patient or between a health volunteer and a malaria
patient in the community or at home particularly on the use of personal preventive
measures against malaria.
(1) counseling of malaria clients by trained health care provider particularly on proper
treatment, the need to come back for follow-up smears and indications for referral
to higher level of facility
(2) conduct of bench conference or orientation of malaria patients on how to use the
ITNs and other preventive measures in the environment.
(3) orienting community volunteers on how to undertake indoor residual spraying;
(4) orienting treatment partners how to administer the anti-malarial drugs and how to
report the results of treatment.
(5) development of local IEC materials to support the above health promotion
activities.
E. Re-orienting Health Services
Reorienting health service delivery requires a change in the mindset and perspective of
health service providers beyond provision of clinical and curative services. It involves
sensitivity to cultural differences and preferences and recognition of the diversity in local
situations and needs. In the context of a changing malaria epidemiology, it also requires a
shift in orientation from control to pre-elimination and eventual elimination. Which in turn,
will involve updating of knowledge and skills, and adoption of a extra sense of vigilance.

Health Service Reorientation Activities
In Support to Malaria Prevention, Control and Elimination
(1) promotion of the use of the revised stratification criteria and scheme in determining
appropriate intervention package.
(2) training of health providers and managers on on the updated manual of operations for
the program
(3) continuous updating of standards and protocols on quality assurance of malaria
interventions (i.e. diagnosis, drug efficacy, vector control interventions) based on
research and evaluation
VI. Guidelines
A. Formulation of Local Health Promotion Plan
All local government health units shall develop a Health Promotion Plan guided by the
following steps:
Step 1. Analyze the health situation
The first step in formulating the Health Promotion Plan is to make a comprehensive
assessment of the malaria situation in the locality. Analysis of the malaria situation
entails the collection, organization and analysis of data in terms of the current status
of malaria problem in the locality, the identification of factors influencing the malaria
situation, the current behavior of the target clients and prioritizing the health promotion
issues or problems to be addressed.
Step 2. Formulate Health Promotion Goal and Objectives
Goal and objectives are those that are desired to be achieved within a given time
period through the use of different strategies and resources. These are based on the
identified priority health promotion issues or problems and should be aligned with the
goal of the Malaria Program. The objectives should clearly state the actions expected
of the identified target audience.
Step 3. Formulate Strategies and Action Points
Identify next the key strategies and action points you need to undertake in order to
achieve the set objectives. Take note the following summary of key strategies and
action points as earlier defined under Guiding Principles - Section IV.
Step 4. Indicate Timelines for Each Action
Indicate the expected timelines each of the action points or activities will be
implemented. You may express these in terms of months or quarters per year.
Step 5. Identify Locus of Responsibility

The locus of responsibility is the lead individual directly responsible for the conduct or
completion of the planned activity or action point. It is important that the lead person
responsible will be specified and not the office/agency.
Step 6. Determine Required Resources
Resources required to support health promotion activities must be identified, including

the source. Internal sources include the budget of the local government, and DOH
national and regional offices, while external sources include other government
institutions, development partners or donors and the community.
B. Development of IEC Messages
The development of effective IEC messages and health promotion materials is a basic step in
mounting health promotion activities intended to effect the desired changes in the
awareness/knowledge, attitudes and practices of the different target audiences. .
B.1 Key Messages By Stratification Categories
In support of the overall malaria program direction towards elimination, there is a need
to focus key messages on various groups of stakeholders in areas of different
stratification status. Table 3.28 summarizes the key messages that need to be
emphasized in each particular stratification classification.

Malaria Communication Plan
Changing to a desired behaviour is the purpose of health promotion. There are several
stakeholders in malaria elimination and each stake holder needs to practice the desired
behaviour for NMCEP to succeed. Listed below are the key messages to malaria stakeholder
and the responsible person to send the message. It is upon the responsible person to decide
on the channel to carry the key messages.
Table 3.24 Malaria Communication Plan

Key Message Target Audience Responsible Person
Sleep inside mosquito net every Community members MHO, Hospital doctors and nurses,
night Individual person seeking PHN, Microscopist, RSI, BHW,
consultation Spray man, FAW,
Keep your child inside mosquito Mothers MHO, Hospital doctors and nurses,
net every night PHN, Microscopist, RSI, BHW,
Spray man, FAW,
Seek early consultation Community members MHO, Hospital doctors and nurses,
Individual person seeking PHN, Microscopist, RSI, BHW,
consultation Spray man, FAW,
Take complete dose of anti- Confirmed malaria MHO, PHN, Microscopist, RHM,
malaria medicines patients Hospital nurses and MD’s
Construct and maintain bio pond Community Leaders MHO, PHN, RHM, RSI, BHW
Clear the stream banks and seed Community Leaders and MHO, PHN, RHM, RSI, BHW
with larvivorous fish households near the
breeding site
Test before you treat RHM, PHN, MHO Provincial and Regional Program
Hospital MD’s Managers
Wash LLIN every quarter LLIN recipients MHO, PHN, RHM, RSI, BHW
Use mild soap in washing LLIN LLIN recipients MHO, PHN, RHM, RSI, BHW
Keep mosquito net intact. Patch LLIN recipients PHN, RHM, RSI, BHW
up holes in the net. Community members
Have your blood check for Returning OFW BHW, Community Leaders, RHM,
malaria PHN
DOLE, OWWA
Beware of Malaria Leaving OFW National Malaria Program
Protect yourself from mosquito Manager,
bite RMC through DFA, DOLE, OWWA
Take your malaria prophylaxis Leaving OFW National Malaria Program Manager
as prescribed and RMC through DFA, DOLE,
OWWA
Warn our outgoing and incoming DOLE, OWWA, DFA, National Malaria Program
OFW about malaria in their Recruitment Agencies Manager,
destination. RMC, PMC
Keep your province malaria free, LCE PDOHO/DMO, PHO/Provincial
support malaria elimination hub Malaria Coordinators
Keep your municipality/city LCE, MHO, CHO RMC, PDOHO/DMO,
malaria free support campaign PHO/Provincial Malaria
for mosquito control Coordinators, MMC

UNIT IV Program Management
Policy Direction
Local capacities of malaria program management will be strengthened and coordination among and
between levels of administration relative to malaria program efforts and resources will be
streamlined.
Efforts will be exerted for LGU’s to design or adopt financing mechanism to sustain malaria operation
towards elimination and to maintain their malaria-free status.
1 Implementation Arrangement
Department of Health (DOH) national office provides direction for the national programs. This
is the National Objectives for Health (NOH). This direction is in sync with global agenda, the
Sustainable Development Goals (SDG), Global Technical Strategy (GTS), and Framework for
Malaria Elimination of WHO. The national office develops long and medium term development
plans and recommends strategies to attain the health objectives. The strategies are contained
in the National Strategic Plan (NSP). It also contains the activities that must be accomplished
to attain the goal. Milestones are identified to gauge progress. The strategic plan is converted
to a short term plans called annual operational plans where specific activities and target
accomplishments are written. The plan is then implemented and progress is monitored using
predetermined indicators.
Local government units are recommended to follow the NSP to guide them in the attainment
of NOH. Support in terms of funds, commodities, training and technical assistance are
provided by the national and regional offices to the local government units. The national office
collaborates with other international and local development partners for attainment of SDG.
Clear roles, division of labour and standards are basic requirements for achievement of health
goals by a system segmented by law. LGU health system must follow the standards set by
the national office but LGU can innovate to achieve the common goal which is malaria control
and eventually elimination.
2 Planning
2.1 Annual Operational Plan
National strategic plan is converted to a more detailed annual operational plan (AOP) for
implementation. Proposed AOP is made before the incoming year and revised when the final
budget for year is approved. Steps in preparing AOP are as follows:
1. Review the operation of the previous year and evaluate the outcome of activities based
on the reduction of cases.
2. Identify the necessary innovations for the improvement of program implementation.
3. Update stratification of barangays and summarize the number of houses and
population by stratum.

It is recommended that the plan is in Excel® Software spreadsheet for ease in doing
computations, summaries and M&E planning.
4. Determine the necessary activity based on stratum (Table 3.3 Stratification)

5. Determine the targets for each activity using the updated stratification data
6. Determine the resources needed by each activity and compute for the cost (Annex 9
Computation of logistics)
7. Determine the indicator for each activity based on the NSP indicator number.
Additional indicators can be identified for local (municipal and provincial) program use.
8. Determine the budget code for each activity
9. Summarize the AOP and the budget
10. Submit AOP for final approval and provide copy to the PHO.
11. Prepare monitoring plan for the AOP
2.2 Activities/Strategies at the Municipal and City level
All malaria control and elimination operation level must perform their function to deliver the
desired output. Municipal and City Health Offices are at the forefront of malaria control and
elimination. All the activities and strategies of all health programs including malaria program
converge at the city and municipal health offices. They are multi-tasks to deliver health
services to the community. All health programs are competing for the fully loaded time of the
frontline health workers. The typical staffing patterns in RHU/CHO and PHO are in Table 4.1
and Table 4.2. I t also contain their specific role in MCEP and the necessary training to perform
their duties and contribute to the achievement of goal.
Table 4.1 RHU Staff and their Roles in NMCEP

RHU/CHO Staff Activities/Output Training Needed
Municipal/City Health Allocates budget for Malaria Field Operations Training
Officer malaria program Malaria Epidemic Management
Planning Malaria Elimination Training
Monitoring and Evaluation
Case management
Health Promotion
Municipal/City Malaria Planning Malaria Field Operations Training
Coordinator (Designated by Monitoring and Evaluation Malaria Epidemic Management
the MHO from among RHU Inventory management Training
staff) Stratification Reporting and
Recording

Continuation Table 4.1
(cont.) RHU/CHO Staff Activities/Output Training Needed

Public Health Nurse Reporting and Recording Malaria Field Operations Training
Stratification RDT TOT
Logistics management Logistics Management Training
Health Promotion
Collaboration with other
local sectors
Medical Technologist/ Laboratory Diagnosis Basic Malaria Microscopy
Municipal Validator Health Promotion Refresher course for Malaria
Microscopy report Microscopy
MESU Officer (designated Surveillance, PIDSR
by the MHO from among Recording, reporting, data Malaria Epidemic Management
the RHU staff) analysis Training
Rural Sanitation Inspector Stratification Malaria Field Operations Training

Vector Control IRS Training
Vector Surveillance Training on Basic Entomology
Case Foci Investigation Epidemic Management Training
LLIN Distribution
Foci Management
Health Promotion
Community Organizing
Development project
monitoring
Rural Health Midwife Malaria Surveillance Malaria Field Operation Training
PCD/ACD RDT Training
Case management
LLIN Distribution
RDT testing
Health Promotion
Community Organizing
Casual Workers ACD Blood smear preparation
IRS IRS Training
Health Promotion
Volunteer Microscopist Malaria Microscopy Microscopy training for non-MedTech
Case Management
RDT Volunteer RDT Testing RDT Training

Case Management
Health Promotion
Volunteer Health Worker Information Dissemination Basic BHW Training
Screening of migrants and
visitors
Health Promotion
Assist in Community
Organizing

2.3 Activities/Strategies at the Provincial Level
Table 4.2 PHO Staff and their role in NMCEP

Provincial Staff Activity/Output Training Need
PHO Allocates fund for MCEP
Establish malaria elimination hub
Provincial Malaria Coordinator Planning Malaria Field Operations Training
Monitoring and Evaluation Epidemic Management Training
Provides Technical Assistance to
RHU/CHO
Evaluates/Consolidate Municipal
Operational plans
Recording and reporting
Logistics management
Assure readily available anti-malaria
medicine in the province accessible
within 24 hours.
Leads epidemic response
Facilitates training of RHU/CHO staff
in coordination with CHD
Keeps inventory of skills
Malaria Register filing
PESU Officer Surveillance PIDSR Training
Collection, analysis of data
Provide feedback to MESU and RESU
Leads in epidemic investigation
HEPO Design information material suited for
the local situation
Develop collaboration with other
stakeholders
Provincial Staff Activity/Output Training Need
Supply Officer Warehousing of malaria commodities Logistic management training
Inventory management
Provincial Vector Control Vector Surveillance Malaria Field Operations Training
Officer/Sanitary Engr./SI Provides Assistance to RHU/CHO in Basic Entomology Training
Entomologist Designate foci management
Assist in QA of vector control
measures
Functions as entomologist of the
province
Provincial Validator/City Supervise municipal microscopist Microscopy Training
Validator Implement microscopy QA Proficiency Assessment for
Validators
Supervisory Training
Casual Workers Indoor Residual Spraying IRS Training
(The province hires casual Active Case Detection
workers (Spm, SqL, Ento aide)
with support from CHD)

Continuation Table 4.2
Malaria Elimination Hub
Provincial and District Hospital
(and DOH retained hospitals)
Resident Physician (Pedia and Provides treatment of complicated and Severe Malaria Management
IM) uncomplicated malaria among in Training
patients
Hospital Pharmacist Provide 24/7 availability of anti-
malaria medicines
Chief Nurse/ Infection Control Reports malaria cases with 24 hours
Nurse to PESU
OPD Nurse Supervisor Report outpatient malaria patients to
Chief Nurse
Hospital Laboratory Provides laboratory diagnosis of Malaria Microscopy Training; RDT
malaria (Microscopy and RDT) Training
Submit report to the ESU
2.4 Activities/Strategies at the Regional Level

Table 4.3 Regional Staff and their Roles in NMCEP
RO/ Staff Roles/Output Training Needed
Regional Director Allocates fund for MCEP
Program Manager/ Expert/ Provides Technical Assistance MMFO
Regional Malaria Coordinator Training Epidemic Management
(RMC) Inventory Management
M&E
Evaluate Provincial AOP
Provides Support to Provincial
MCEP
RESU Officer Collection and analysis of case PIDSR Training
reports
Provides feedback to PESU,
Epidemiology Bureau and RMC
Regional Entomologist Conducts QA; IR Monitoring; Diploma in Applied Practical
Conducts entomological Entomology (DAPE)
investigation;
Facilitates entomology training;
Submits report
Regional Validator Conducts QA Supervisory Training
Facilitates Microscopy Training; Pass Assessment for
submits Validators
report
Supply Officer Warehousing and distribution Logistics Management Training
of malaria commodities
Facilitates procurement
Casual Workers/ Job Order Assist in the implementation of As per TOR
the program

2.5 Activities/Strategies at the National
Table 4.4 National Agencies and Their Roles in NMCEP

National Agencies/Committees Roles Training Required
DOH-IDO- Malaria Program Formulates policy on all aspect of malaria
Manager control and elimination program
Prepares strategic plans
Formulate guidelines
Set standards
Allocate funds
Procurement and allocation of malaria
commodities
Provide Technical assistance
Conduct Training
Monitoring and evaluation
Provide inputs in the health promotion
strategies
Coordinate with the Regional Offices and
other DOH bureaus/division and
government agencies
Collaborate with other development
partners
Malaria Technical Working Provide technical assistance

Group (refer to AO) Assist in monitoring and evaluation
Epidemiology Bureau Malaria Disease Surveillance

Data Base Management
Health Promotion Provides technical assistance

Evaluates the effectiveness of existing
communication strategy Coordinates with
the NPM
Modify Communication Plan for malaria
RITM Provides technical assistance in the

development of guidelines/SOPs/training/
OR protocols on the ff:
 Therapeutic Efficacy Study
 QA of RDTs/ Microscopy
 QA of vector control (LLIN)
 Insecticide resistance monitoring
 LLIN durability study
 Program Identified researches
Disseminate results
Provide PCR confirmation (and provide
training in RO with PCR machine)
Conduct TOT as needed (including GIS)
Development Partners Provides technical assistance
Capability Building
Provides venue for coordination/
collaboration with other government
agencies and sectors

3 Logistics Management
Policy Direction
The program will ensure universal access to early diagnosis and prompt treatment. Treatment must
make use of effective anti-malarial drugs, with guidance from results of up-to-date efficacy studies
done in the country.
Changing malaria situation in the country dictates changes in managing commodities for
malaria program. Anti-malaria medicine is not readily available in private drugstores but cases
of imported malaria surface from time to time. Malaria program policy states that confirmed
malaria must receive treatment within 24 to 48 hours. Malaria supplies must be available within
a few hours travel from any point in the country. Keeping anti-malaria medicine in every
barangay health station is ideal but it will entail huge inventory cost and wastage considering
absence of local cases in 76 of 84 provinces in the country. Provincial malaria point person
must identify strategic location where the medicine can be access and must inform the RHUs
and private hospitals/clinics where and how it can be accessed. Table 4.5 is a list of malaria
commodities. The national office procures and allocates them by region who in turn allocates
them by province. Allocation will depend on the need of the province and the need will be
computed from routine malaria reports from the provinces and municipalities. Reports with
high quality are required for better allocation of commodities to prevent stock outs on one end
and huge inventory cost on the other end. The LGUs can augment malaria commodities from
their own budget provided they are of high quality and follow the standard set by the DOH.
The computation of requirements is in Annex 8.
Table 4.5 Malaria Activities and the Needed Resources

Activity Malaria Commodities
Diagnostic RDT Lancets
Slides Giemsa
Case Management
Artemether- Lumifantrine Quinine tab
ACT6x1 Artesunate vial
ACT6x2 Primaquine
ACT6x3 Chloroquine
ACT6x4 Doxycycline
Artesunate suppository Other anti-malarial
drugs
Artesunate IV
Vector Control
LLIN PPE set
Single Spray can repair kit
Family
Insecticide
Spray can
Note: Computation of requirements are in Annex 8

3.1 Malaria Commodity Stock Level for Malaria-Free and Zero Indigenous Provinces
Universal access to malaria diagnosis and treatment must be followed even if the province
has no local cases anymore. Malaria acquired outside the province and those carried by OFW
are continuing threats to life and re-introduction of malaria. They should receive diagnosis and
treatment services within 24 to 48 hours. Each province must be ready to provide diagnosis
and treatment within the prescribed period. They must store adequate volume of malaria
commodities to respond quickly. Table 4.6 below shows the stock level for each health clinic
in malaria free and zero indigenous provinces. Stock level for control provinces will depend
on the reported usage of the commodities and projections based on the AOP. Inventory must
be monitored every month and physical count done quarterly.
Table 4.6 Stocking level for Malaria-free and Zero Indigenous Provinces
Item RHU/CHO/DHO Stock PHO/Elimination Regional Stock
Level Hub/ Designated Level
Referral Facility
Stock Level
RDT kit (box of 25 1 4 Multiply by the

tests) number of
provinces and
referral facility- for
RDT, medicines
and insecticides
A L 4x6 (good for 5 2 2 1
pat/tx facility)2-2-1
Chloroquine (box of 1 2
100’s)
Primaquine (box of 1 2
100’s)
Quinine 500 mg tab 1 2

(bot x100)
Quinine Ampoule 300 20

mg/ml
Giemsa Stock 500 ml/RHU Giemsa Powder in
Solution Collaboration
Centers/Giemsa
Production Centers

Table 4.6 continuation
Item RHU/CHO Stock Level PHO Stock Level Regional Stock
Level
Artesunate
60mg/ampoule 30
Vector Control
LLIN pcs 500
Spray can (pcs) 10
Insecticide sachet for
IRS 500
Insecticide for
mosquito net 500
treatment (tab/sachet)
Provincial malaria coordinators (PMC) oversee availability of malaria commodities to each

RHU/CHO and elimination hubs and maintain the prescribed stock level at all times. PMC see
to it that each health unit, including provincial and district hospital, know where and how to
access malaria commodities even on weekends and holidays (24/7).
4 Reporting and Recording
Evidence based decision making is the hallmark of malaria elimination. Sharing of data
through regular and special reports is necessary at each level for objective assessment of
implementation. A good quality report has correct data entry, complete and on time. Feedback
to the sender must be made and must have comments, analysis and recommendations. This
will inform the sender that the reports do not just sit on filing cabinets. List of malaria reports
is in table 4.7 and Table 4.8. Forms can be downloaded at
http://www.doh.gov.ph/publications/non-serials.
Table 4.7 Reports to the Regional and National Level

Title of Report Source Document
Malaria Cases and Death Report Malaria Case Registry and Malaria
Malaria Cases and Death Quarterly Report Laboratory Registry
Malaria Cases and Death Annual Report
Vector Control Report Malaria Vector Control Registry
Vector Control Semi-Annual Report
Vector Control Annual Report
Malaria Financial Report Budget Utilization Rate
Malaria Budget Annual Report
Malaria Commodity Inventory Report National Online Stock Inventory
Malaria Commodity Inventory Semi-Annual Report Reporting System (NOSIRS)
Malaria Commodity Inventory Annual Report
Diagnostic and Quality Assurance Report Malaria Laboratory Registry
Malaria Diagnostic and Quality Assurance Quarterly
Report Malaria Blood Film Report
Malaria Diagnostic and Quality Assurance Annual Report

4.1 Local Records and Reports
Table 4.8 Records and Reports at the Municipal/CHO level

Regular Activity Report
IRS Daily Spray man’s Report
IRS summary Report
Vector Control Registry
LLIN Distribution LLIN Distribution Form
LLIN Distribution Summary Report
Vector Control Registry
Active Cases Detection ACD/MSAT Form
ACD/MSAT Summary Form
Passive Case Detection Malaria Case Report
Malaria Case Registry
Laboratory Log Book
Monthly Malaria Laboratory Report
5 Program Monitoring and Evaluation
Monitoring and evaluation are basic functions of program managers just like planning.
Monitoring is regular viewing of indicators to have an idea whether the objective/goal of the
plan will be achieved. Monitoring is looking for problems that hinder achievement of
objective/goal. Indicators will help identify existence of problem early enough to have time to
rectify the situation and then make necessary corrective action to reach the goal. To cite an
example, suppose a report says 100% LLIN distribution (input indicator) but there is no
reduction of cases (impact indicator). The impact indicator is telling us there is a problem even
if the input is 100% achieved. It is upon the program manager to investigate the root cause of
the problem and institute corrective measures before the endpoint of the plan to attain the
objective/goal of the plan.
The first step in monitoring is preparing a monitoring plan (Table 4.9). The M&E plan is
based on the approved plan (NSP or AOP).

Table 4.9 Basic Steps in Monitoring and Evaluation
Step Activity Example
1 Study the program plan NSP
2 Make M&E plan consisting of
a. Schedule (Gantt Chart)
b. Inputs (activities) and their corresponding indicators to the
Gantt Charts
c. Milestones
d. Estimate cost
3 Gather the data as scheduled in the Gantt Chart
4 Compare the impact indicator vs. the target 2017 cases vs. 5 yr
average no. of cases
5 Brainstorm possible sources of discrepancy (variance) and gather
evidence/information.
6 Look at each input indicator and compare vs. target
7 Assess each input using the following guide questions
Is it the right input to produce direct impact?
Is the input in the right time?
Is the input in the right place?
Is the input in the right quantity?
Is the input of the right quality?
8 Decide for the corrective measures to achieve the goal (impact).
5.1 Monitoring by the National and Regional Level
Monitoring and evaluation for the regional and national level is wider in scope and the basis is
the activities and targets written in the most recent National Strategic Plan. It follows the basic
steps in M&E starting with M&E plan. Qualitative information gathering is also included in data
collection to provide substance to the numerical targets. Result of the M&E activities are then
used to improve the program quality. A template for M&E plan is shown Annex 10. Monitoring
for the national level is a collaborative effort of all the agencies, committees and all
organization involve in NMCEP.
5.2 Monitoring at the RHU/CHO and PHO Level
The objective of monitoring is to identify gaps/problem/wastage and look for solution before
the end of the AOP. Below is an example of monitoring activity schedule at the municipal and
provincial level (Table 4.10).

Table 4.10 Sample monitoring plan for RHU malaria control and elimination program
Activity Indicator Ja Fe Ma Ap Ma Ju Ju Au Sep Oc No De
n b r r y n l g t t v c
Stratificatio Stratified X
n Data list of
Barangay
Local Fund Approved X
for malaria local
budget for
malaria
Malaria No. of X X X X X X X X X X X X
Cases cases
QA Glass slide X X
Microscopy film report
IRS Coverage X X X X
of IRS
ACD SPR X X X X
BER
LLIN Distribution X X X X
Coverage
LLIN
Usage
Case-Foci Percent X X X X
investigatio Investigate
n d
Health X X X X
Promotion
Community X X X X
Mobilisation
Inventory Stock out X X X X
rate
Fund Utilisation X X X X
Utilisation rate
Evaluation X X
and catch-
up planning
Even if the indicators are showing that the program is doing well there may be some minor
problems that can be solved and provide more efficiency to operation. Small improvements
add up to give huge result. Asking the right questions will lead to discovery and understanding
of the situation. Table 4.11 is a list of some guide questions in monitoring the program and
identify problem situation.
Table 4.11 Some Guide Questions for Monitoring and Evaluation
Monitoring/Evaluation Indicator Formula Source of data Probable

Questions Problems/Remarks
(to mention a few)
Where are the cases Monthly PIDSR Epidemic
this month? cases/Bgy
What is the problem
barangay/sitio?

Monitoring/Evaluation Indicator Formula Source of data Probable
Questions Problems/Remarks
(to mention a few)
Is there vector control % House (No. of IRS Report Insecticide
in place? sprayed houses resistance
When was it applied? sprayed ÷ Quality of spraying
Is it working? Total target Change in vector
number of behaviour
house) x
100
% LLIN LLIN Distribution Low LLIN use
Ownership report Holes/Tears in
LLIN
% Mortality of Bioassay Insecticide
mosquitoes resistance
Are we detecting Slide Positive (No. of Microscopy report High SPR is
significant number of Rate (SPR) positive PCD/ACD indicative of
cases to cause or smear ÷ inadequate case
reduction? Test Positive Total detection.
rate (TPR) number of It may also mean
smear) x there is epidemic.
100
Did we exert enough Annual Blood (Total PCD/ACD Low ABER creates
effort to find the cases? Examination number of doubt on the “real”
Rate (ABER) smear ÷ incidence of
Endemic malaria.
population)
x 100
Are we winning the Percent Pf (No. Pf ÷ PIDSR/PCD/ACD Normally Pf is about
battle? total pos) 70%. Reduction in
x100 proportion of Pf
means the
interventions are
working. It can also
mean there is Pv
epidemic.
Are we going to hit the Compare PIDSR / PCD Lower monthly
target reduction of monthly cases Report cases each month
annual parasite with that of will translate to
incidence (API) at the last year. lower API at the end
end of the year of the year.
It is unwise to
compute monthly
parasite incidence.
Do we have efficient Stock out No. of Inventory report Poor distribution
logistics management? rates clinics system.
reporting Poor re-ordering
stock out ÷ system
Total no. of
clinics

5.3 Malaria Program Indicators
There are many indicators in the program. The inputs in the plan determine the kind of indicator that
will be collected to gauge progress of plan implementation. Basically indicators are the evidences that
show progress or attainment of objectives and goal. All the indicators are predetermined by the National
Strategic Plan. Some of the more common program indicators and their significance are listed in Table
4.12 below (source Philippine National Malaria Monitoring and Evaluation Plan 2014-2020).
Table 4.12 Selected program indicators and their significance

Indicator Significance
Malaria morbidity rate Measures trend of malaria morbidity and
highlights location and quantity of
transmission.
Malaria mortality rate Monitors the impact of the malaria
program on severe diseases and death.
Annual Parasite Incidence (API) Tracks the trend in malaria endemicity
Annual blood examination rate (ABER) Signifies adequacy of cases detection.
For active and residual non active. (suspected tested Increase level of confidence in “zero-
pos/endemic pop) ness” of cases in the area.
Slide positivity rate (SPR) or Test Positivity Rate (TPR) Proportion of positives tests in a given
sample. It triangulates ABER.
Pf gametocyte rate Signifies delay either in diagnosis, or
treatment seeking or case detection.
Gametocytes of Pf are formed after more
than seven days of symptoms.
5.4 Monitoring Progress of Malaria Elimination at the Provincial Level
Malaria elimination is not only interruption of transmission but removal of parasite in each
and every parasite reservoir in the locality. The indicator suggested for malaria elimination is
the Percentage of Barangays/sitios under cleared stratum. It must be 100% five years before
2030. It must be supported by ABER of 1-2%.

6 Quality Assurance
Malaria elimination relies on implementation with little margin of error. Malaria bounce back
rapidly (outbreak) even with one case or parasite left in the community. There is no room for
error in diagnosis and high quality vector control is necessary in elimination setting. Quality is
also expected in reports based on timeliness and correctness of content.
6.1 Quality in Malaria Rapid Diagnostic Tests
Procured RDT is subjected to lot quality assurance test by RITM upon delivery in the country
prior to distribution to end users. The batch that failed the test is returned to the supplier.
6.2 Quality Assurance for Microscopy
Malaria elimination requires high quality diagnosis because one missed case has a potential
to re-introduce the parasite to the community. Microscopy has to be of high quality meaning
the skill of microscopist must meet the standard needed by the elimination program.
Each malaria microscopist is regularly visited by their designated validators. Supervisory visit
is guided by a checklist for a thorough observation of the workplace, equipment and output of
the microscopist. Performance of the supervisee is gauged through cross reading of blood
smears. Microcopists who underperform are sent for refresher training.
Selection of blood smears for validation
Malaria Free Province

 Any positive blood film must be submitted to Regional Collaboration Center and
blood spots on filter paper must be submitted immediately to National Reference
Laboratory (NRL) for confirmation by nucleic acid amplification assay
 Microscopists must enrol and pass in National External Quality Assurance (NEQAS)
in Parasitology.
Zero- Indigenous Malaria Provinces
a. Immediate cross checking of reported positive cases

Submit positive blood film immediately to the assigned validator and dried blood spots on
filter paper to the RITM (NRL-for Malaria) for confirmation by molecular assays.
b. Regular Cross checking/validation

Table 4.13 Procedure for selection of blood films for validation in zero-indigenous
malaria provinces
Step Action Notes
1 Collect all positive slides
2 Keep all negative blood films until validated
3 If blood films are less than 30, fill up Form 1 and
submit together with blood films in a properly
labelled envelop to the validator.
4 If blood films are more than 30, ask the immediate
supervisor to randomly select 10% , fill up Form 1
and submit together with blood films to the
validator in a properly labelled envelop
5 For mass blood survey (MBS) all positive blood
films and 10% of the negative blood films are
submitted for validation.
6 If no blood film was examined write “NO BLOOD
FILM EXAMINED” in Form 1 and submit to
validator.
7 Validator reads the blood film and provides
feedback within 2 to 4 weeks.
8 Validators send a panel of blood films to the Refer to WHO Quality
microscopist to be examined for 2 weeks and send Assurance Manual for
back result to validator for checking more detail.
Active Provinces
Table 4.14 Procedure for selection of blood films for validation in active provinces
(AP) category
Steps Action Notes
1 Keep all blood films until validated Submit positive blood film P malariae
or P ovale to the assigned validator
plus dried blood spots on filter paper
to the RITM (NRL-for Malaria) for
confirmation by molecular assays.

Steps Action Notes
2 Prepare slides for selection of samples Choose a method for selection of
smears for validation. Either systematic
Separate slides by month. sampling method or simple random
sampling method is sufficient for slide
Separate positive and negative slides selection. Sampling procedure is
by month detailed below.
Select 5 positive smears and 5 a. Systematic sampling method

negative smears for each month using -Arrange the slide by their slide number
either systematic sampling or simple -Get the total number of positive slides
random sampling as shown in the right. for the month and divide by 5.
-Round the quotient to make a whole
If positive smear is less than 5 then number.
submit all for validation. - Example
Total number of negative slide = 45
If blood smear is less than ten, then Divide 45 by 5 = 9
submit all for validation. Then every 9th slide is included in the
sample for validation
Repeat the procedure for negative
slide
b. Simple random sampling method

-Assign a number for each positive
slide
-Make numbered papers equal to the
number of slides and put them in a box.
-Shake the box and draw 5 numbers.
These will be the slides for validation.
-Repeat the procedure for selection of
negative slides
3 Fill up Form 1 and place in an envelop One envelop for each month.
4 Seal envelop and write the name of the If no blood smear was examined put
facility and the microscopist and their “NO BLOOD FILMS EXAMINED” in
code number. Form 1.
5 Send envelop together with the slides

placed in a slide box to the assigned
validator
6 Validator reads the blood film and Refer to Quality Assurance Manual for
provides feedback within 2 to 4 weeks. more detail.

6.3 Quality Assurance in Vector Control
Quality of vector control input is first assured by determining the sensitivity (Susceptibility test)
of the vector to the insecticide prior to use and monitoring the effectivity of insecticide after its
application (Bioassay test)
The program uses insecticides that passed WHO Pre Qualification Team-Vector Control
(WHO-PQT-VC).
Susceptibility of the vectors to the insecticide being used in IRS and incorporated in LLIN
should be done every 2 years per province by regional entomologists.
The quality of IRS is tested through bioassay of the sprayed walls within 1 week of application
and 3 months later.
LLIN are also subjected to bioassay yearly. Residual efficacy evaluation of LLIN samples are
tested every year. Samples are collected by regional entomologist with technical supervision
from RITM.
Susceptibility Testing of Adult Mosquitoes to Insecticide

 Physiological resistance is the ability of a population of insects to tolerate doses of an
insecticide which would prove lethal to the majority of individuals in a normal population
of the same species.
 Susceptibility tests are carried out to determine the proportion of vector population that
is physiologically resistant to a particular insecticide.
 It is performed to select new insecticide for vector control or to monitor performance of

insecticide in current use.
Materials and Equipment
 WHO Susceptibility kit

 Exposure/Holding tubes
 Copper and silver rings
 Insecticide impregnated filter papers
 Oil impregnated control papers
 Sucking tubes
 Nylon netting
 Rubber bands
 Cotton
 Timer
 Mosquito tray
 Scissors
 Masking tape
 Sugar solution
 Impregnated nets
 Untreated nets
 Hygrometer
 Stereoscope
 Mosquito cage
Procedure for conducting susceptibility test is detailed in Annex 10.

Bioassay Tests
Objectives of bioassay tests

 Determine the residual efficacy of an insecticide in a sprayed wall
 Evaluate the quality of spraying operation
 Determine the residual efficacy of an insecticide on bed nets and other materials like
curtain
 Assess quality of treatment on bed nets
 Bioassay is done within 1 week after IRS and repeated after three months to
compare mortality rates.
 Details of the procedure is in Annex 11
Materials /Equipment:
 Bioassay Kit
 Plastic cones
 Adhesive sponge tape
 sucking tubes(bent or straight)
 Straight sucking tubes
 Paper cups(preferably white color)
 Nylon netting
 Rubber bands
 Cotton
 Timer

 Mosquito tray
 Scissors
 Masking tape
 Result sheet
 10% Sugar solution(e.g. 10g of sugar dissolve in 90ml clean water)
 Insecticide treated bed nets (for testing)
 Untreated nets (for control)
 Hygrometer
 Stereoscope

Bibliography
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List of Figures
Page
Fig. 1.1 Malaria Paroxysm 2
Fig. 1.2 Malaria Endemic Countries 3
Fig. 1.3 Malaria Endemicity Map, 2010 – 2016 5
Fig. 2.1 Interplay of factors in the environment determines malaria transmission. 10
Fig 3.1 Components of Malaria Focus 16
Fig. 3.2 Sample of cassette type RDT (Different brands may have different design and 41
procedure. Always read the accompanying leaflet before using RDT kit).
Fig. 3.3 Appearance of RDT Cassette after reaction time with result lines 42
Fig.3.4 Spray can and the fan shape discharge of T-Jet 8002 nozzle tip 62

List of Tables
Table1.1 Category List of Provinces 5

Table 2.1 Selected Characteristics of Malaria Vectors in the Philippines 11
Table 2.2 Location and Stages of Parasite Life Cycle 12
Table 2.3 Number of Offspring from a Single Parasite 13
Table 3.1 Classification of malaria foci 21
Table 3.2 Package of intervention per malaria focus 22
Table 3.3 Comparison of Utilization of Surveillance Data between Active Provinces 24
and Malaria free/zero Indigenous Malaria Provinces
Table 3.4 Varieties of active case detection 24
Table 3.5 Response to PCD Malaria Report from Zero-indigenous malaria province 27
(Z province), residual non-active and cleared barangays of Active provinces
(A province), and malaria-free provinces (MF province)
Table 3.6 Response to PCD reports from active foci barangays. 28
Table 3.7 Steps in 1-3-5 response strategy 35
Table 3.8 Code for Microscopy Result 39
Table 3.9 Target antigens of commercially available RDTs 40
Table 3.10 List of Medicines for Treatment of Malaria and Complications 44
Table 3.11 Malaria Treatment Directory 46
Table 3.12 Dosing Schedule of Artemeter Lumifantrine (AL) 48
Table 3.13 Dosing Schedule of Primaquine (PQ) as Anti-Gametocyte 49
Table 3.14 Dosing Schedule for Chloroquine (CQ) 50
Table 3.15 Dosing Schedule for Primaquine (PQ) Anti-relapse Treatment 51
Table 3.16 Dosing Schedule for Artesunate IV 52
Table 3.17 Dosing Schedule for Artesunate Suppository 52
Table 3.18 Dosing Computation for Quinine plus Antibiotic 53
Table 3.19 Management of Malaria Complications 54
Table 3.20 Treatment Response 57
Table 3.21 Purpose and Types of Vector Control 58

List of Tables (continuation)
Table 3.22 Procedure for LLIN Distribution 60

Table 3.23 List of WHOPES Approved Insecticides for IRS 62
Table 3.24 Malaria Communication Plan 70
Table 4.1 RHU Staff and their Roles in NMCEP 72
Table 4.2 PHO Staff and their role in NMCEP 74
Table 4.3 Regional Staff and their Roles in NMCEP 75
Table 4.4 National Agencies and Their Roles in NMCEP 76
Table 4.5 Malaria Activities and the Needed Resources 77
Table 4.6 Stock level for Malaria-free and Zero Indigenous Provinces 78
Table 4.7 Reports to the Regional and National Level 79
Table 4.8 Records and Reports at the Municipal/CHO level 80
Table 4.9 Basic Steps in Monitoring and Evaluation 81
Table 4.10 Sample monitoring plan for RHU malaria control and elimination program 82
Table 4.11 Selected guide questions for monitoring and evaluation 82
Table 4.12 Selected program indicators and their significance 84
Table 4.13 Procedure for selection of blood films for validation in zero-
indigenous malaria provinces 86
Table 4.14 Procedure for selection of blood films for validation in provinces 86
under active category

List of Annexes
Annex 1 Target activities from National Strategic Plan 2017-2022

Annex 2 Foci registry
Annex 3 Stratification records of barangays/sitos
Annex 4 Malaria case investigation form
Annex 5 Foci investigation form
Annex 6 Monthly malaria records of barangays/sitios
Annex 7 Giemsa staining process
Annex 8 Computation of logistics
Annex 9 M&E Plan Template
Annex 10 Procedure for susceptibility test
Annex 11 Procedure for Bioassay test
Annex 12 Procedures for IRS
Annex 13 Adjunct vector control methods
Annex 14 Reporting forms
Annex 15 Monitoring and Evaluation of IRS

Annex 1
Program Goals and Activities
NSPCEM 2017 – 2022
National Malaria Control and Elimination Program
Base- Target
Indicator line
2016 2017 2018 2019 2020 2021 2022
1. Malaria Cases and Deaths 20% 40% 60% 70% 80% 90%
1.1 Number of confirmed malaria cases
6,604 5,287 3,965 2,644 1,983 1,322 661
reduced by at least 90%
1.2 Number of confirmed malaria
7 5 3 1 0 0 0
deaths reduced to zero
2. Province with API > 1 per 1,000 at-
1 1 1 1 1 1 1
risk population (Palawan)
2.1 Number of confirmed malaria cases
6,132 4,906 3,679 2,453 1,840 1,226 613
reduced by at least 90%
3. Provinces with API < 1 per 1,000 at-
7 7 7 7 6 6 6
risk population
3.1 Number of confirmed, indigenous
malaria cases reduced by at least 394 322 242 161 120 80 40
90%
4. Provinces with zero indigenous
73 74 74 74 75 75 75
malaria cases and malaria free
4.1 Number of provinces with zero
indigenous cases (not yet declared 41 32 19 11 4 3 1
malaria-free)
4.2 No. of provinces declared malaria-
32 42 55 63 71 72 74
free

Strategies and Activities
Strategy 1.1 Maintain focal malaria interventions in municipalities and barangays with stable,
unstable and sporadic transmission
1.1.1 Strengthen diagnostic lab supplies and equipment
1.1.1.1Procure and distribute laboratory supplies and equipment
1.1.1.2 Procure and maintain microscopes
1.1.1.3 Provide RDT kits
1.1.1.4 Procure and distribute G6PD POC test kits: conduct introductory training
1.1.1.5Training on Malaria Microscopy and RDT
a. Train and deploy additional RDT
b. Training on G6PD screening test administration
c. Train on RDT/BMMC supervision
d. On the job training for other RHU staff (non-Med Tech) on RDT
e. Training on Basic Microscopy for newly hired Med Tech as
replacements
f. Refresher training on Malaria Microscopy (BMMC, RHU and Hospitals)
1.1.2 Enhance clinical management and treatment
1.1.2.1 Procure and distribute drugs/medicines
1.1.2.2 Train Health on clinical management course
a. Health personnel from RHU, Public and Private Hospitals
1.1.3 Undertake Vector control measures
1.1.3.1 Procure/distribute LLINs
1.1.3.2 Procure insecticides, spray cans and PPE
1.1.3.3 Conduct IRS (mobilization and orientation of spray men)
1.1.3.3.1 Conduct cross border operations
Strategy 1.2 Ensure continuous access to malaria diagnosis, treatment and preventive
measures in zero-indigenous malaria and malaria-free provinces
1.2. 1 Orient Regions and LGUs on the enhanced Elimination guidelines

1.2.2 Organize Elimination Hub Team per region according to geographical protocol
1.2.3 Establishment of Elimination Hub
1.2.3.1 Assessment of provinces on key requirements of an elimination hub
1.2.3.2 Passage of ordinance/ resolution in support to elimination hub
establishment and operation
1.2.3.3 Provide computer/ printer/UPS/ tablets
1.2.3.4 Provide lab supplies/equipment
1.2.4 Training of health personnel on diagnosis, clinical management, malaria

surveillance and entomology
1.2.4.1 Training and orientation on Malaria Surveillance and Response
Strategy Guide
1.2.4.2 Training on RDT
1.2.4.3 Training on microscopy
1.2.4.4 Clinical Management and treatment

1.2.4.5 Entomology Training
1.2.4.6 Refresher course on entomology
1.2.5 Procurement of drugs/medicine for stockpiles
1.2.6 Procurement of RDT kits
1.2.7 Provision of LLIN
1.2.8 Case detection/Disease Surveillance and Response
1.2.8.1 Case investigation
1.2.8.2 Foci investigation and response
1.2.9 Indoor Residual Spraying
1.2.9.1 Procure insecticide
1.2.9.2 Procure Spray cans
1.2.9.3 Procure PPEs
1.2.9.4 Mobilization of spray men
1.2.10 Border Operations
1.2.11 TA, Assessment and Validation of Malaria Free Provinces
1.2.12 Coordination Meetings and Planning
1.2.13 Continuing IEC and Response
1.2.14 Monitor WHO recommendations and register POC test for G6PD with FDA
(operationalize via Strategy 1.1)
1.2.15 Monitor WHO recommendations and availability of tafenoquine and apply for FDA
registration (operationalize via Strategy 1.1)
Strategy 1.3 Implement responsive malaria interventions among identified vulnerable

population groups
Six other vulnerable or at-risk groups have been identified for further focused intervention:1
i) Forest workers and other informal occupational groups in remote areas;

ii) The military, who are intermittently assigned and re-assigned for field operations;
iii) Overseas Filipino Workers, whose work destination may bring them to high malaria-endemic
countries;
iv) Tourists or constant travellers (both local and international);
v) Those living in communities that become sites of development projects that trigger movements
exposing them to the disease.
vi) Internally displaced populations (IDP) as a result of war or armed conflict, military operations or
occurrence of natural disasters;
1.3.1 Assess which vulnerable groups for focused innovative interventions

(7 vulnerable groups)
1.3.2 Develop Strategy and Operational Plan for Specific Vulnerable Groups
1.3.3. Conduct consultations/meetings and advocacy with identified groups
1.3.4 MOU/MOA between DOH and concerned national/regional/local government
agency
1.3.5 Semi- Annual Coordination meetings
1.3.6 Provide technical support to agencies/ organizations concerned with the vulnerable
groups
1.3.6.1 KAP engagement for IP
1.3.6.2 Other vulnerable groups

Strategy 1.4 Increase demand for and support to effective anti-malaria interventions and
services
1.4.1 Assessment of community-based health promotion events and other media
channels
1.4.2 Develop Health Promotion Plan for Malaria Program
1.4.3 Develop IEC materials (print, video, radio plugs)
1.4.4 Continue integration of malaria messages in selected schools in 8 provinces
1.4.5 Assessment of the outcome of the malaria messages integration in school
curriculum
1.4.6 Integrate malaria IEC during IRS, LLIN distribution, border operations, diagnosis
and treatment sessions: multi-media (IEC print materials, video, radio plugs,
caravan, and poster)
1.4.6.1 Palawan
1.4.6.2 Other Control Provinces
1.4.6.3 Elimination areas
1.4.7 Annual Celebrations (depending on the result of evaluation)
1.4.7 World Malaria Day
1.4.7.1 Malaria Prevention Month
1.4.8 Malaria Program to engage in policy dialogue with other health sector actors
regarding demand-side interventions for KAPs
1.4.9 Engage KAPs in IEC/advocacy for malaria elimination and community mobilization
1.4.10 Treatment hubs for IPs in Palawan (family-friendly outpatient accommodation
near to treatment facilities)
Strategy 2.1 Establish functional organizational structures and malaria work force at all levels
2.1.1 HR Analysis at all levels

2.1.2 Expand personnel compliment at national level to address core functions
2.1.2.1 Entomologist (1)
2.1.2.2 IT person (1c/o KMITS)
2.1.2.3 Technical Writer (1)
2.1.2.4 Regional M& E/Surveillance officer (Palawan, Luzon-Visayas, Mindanao)
and 1 National Level (4)
2.1.3 Include in the DOH – Rationalization Plan the above positions
2.1.4 Advocate among LGUs the designation of Malaria Point Persons to perform cor
functions
2.1.4.1 Negotiate deployment of the following personnel in remote areas
2.1.4.2 DTTB doctors
2.1.4.3 Med Tech Deployment Programs
Strategy 2.2 Strengthen the policy environment, management systems and coordination
mechanism in support of malaria elimination
2.2.1 Finalize, issue and cascade to DOH-ROs and LGUs the following elements of the
MOP related to case management:
2.2.1.1 2nd edition of MOP on Malaria Program
2.2.1.2 AO on DOH Malaria Reporting
2.2.1.3 Revised Clinical Management with referral guidelines and Treatment
Protocol
2.2.2. Develop/Enhance the following manual with accompanying AO/IRR
2.2.2.1 Quality Assurance of Microscopy

2.2.2.2 Quality Assurance for RDTs
2.2.2.3 Retrieval/Disposal of LLINs
2.2.2.4 Guide for Malaria-Free Provinces on Ceasing IRS, LLIN distribution,
border operations, etc.
2.2.2.5 Foci Mapping and Stratification
2.2.2.6 Enhance Guidelines on the assessment/validation and declaration of
malaria-free provinces
Local Strategic and operational plans
2.2.3 Revise and issue M&E Guide based on updated NSPCEM

2.2.3.1 NSPCEM 2017-22 dissemination
2.2.3.2 Development of Sustainability Plan and Road Map
2.2.3.3.Advocacy for LGUs to incorporate malaria interventions in their P/MIPH
and AOP based on Sustainability Plan
2.2.3.4 Assessment and Micro-Planning: Region and Province assisting
municipalities to develop plan for control or elimination
2.2.3.5 Develop Area-Based Micro-Plan (municipal level)
Collaborating Centres
2.2.4.1 Package Training design, Modules Curriculum

2.2.4.1.1 Clinical Management training
2.2.4.1.2 Basic Microscopy (Troubleshooting / Maintenance)
2.2.4.1.3 RDT and RDT QA
2.2.4.1.4. Entomology Training
2.2.4.1.5 IRS Training
2.2.4.2 Organize team of trainers on various courses in each of the 7 collaborating
centers
2.2.4.2.1 Diagnosis (Microscopy and RDT)
2.2.4.2.2 Clinical Management
2.2.4.2.3 Vector Control including Entomology
2.2.4.2.4 Surveillance and Response
2.2.4.3 Support Collaborating Centres
2.2.4.3.1 Replace Davao Collaborating Centre microscope and other equipment
2.2.4.3.2 Establish 3 more CC (2 in Luzon and 1 in Visayas)
2.2.4.3.3 Sustain CC Operations
Logistics Management
2.2.4.4.1 Enhance NOSIERS on malaria commodities (c/o PBSP)

2.2.4.4.2 Distribution of malaria commodities
2.2.4.4.2.1 Commodities in Strategy 1.1
2.2.4.4.2.2 Commodities in Strategy 1.2
2.2.4.4.3 Monitor stock levels (c/o Strategy 4.4)
Management Information System
2.2.4.5.1. Monthly data reconciliation sessions: PHO MCP Coordinator

2.2.4.5.2 Establish Malaria On-Line Information System
2.2.4.5.2.1 Develop the system

2.2.4.5.2.2 Pilot
a. Installation of equipment: hard ware (server, LAN, internet, etc.)
b. Orientation
c. 6-months pilot
2.2.4.5.2.3 Roll out training
Strategy 3.1 Secure adequate government and non-government financial resources in support
of malaria control and elimination
3.1.1 Develop cost-sharing priorities between DOH and LGU

3.1.2 Advocate among provinces and municipalities incorporation of malaria
interventions in their AOP
3.1.3 Integrate as a requirement in the criteria/guideline for issuing Malaria-
Free Certificate the allocation of budget for sustaining Elimination Hub
and advocate adoption
3.1.4 Continue engagement of WHO and other development partners for
technical assistance
3.1.5 Advocate enrolment to PhilHealth (in-patient, IP Benefit Package)
Strategy 4.1 Ensure high quality malaria diagnosis and treatment, through effective quality
assurance systems
4.1.1 Establish QAS baseline indicators and review/revise QAS Forms

4.1.2 Launch and orient Med Techs on the enhanced QAS guidelines
4.1.3 Quality Assurance of microscopy services (National Competency Assessment for
Elimination Hub Med-Tech and potential Validator (Palawan and Provinces with
API <, 1/1000)
4.1.3.1 Pre-qualification of validators from all 82 provinces, 7 CCs and 18
Regions
4.1.3.2 Training on Monitoring and Supervision
4.1.3.3 Slide Banking
4.1.3.4 Validation and onsite visit
4.1.3.5 Panel testing for malaria-free and elimination phase provinces (c/o
Collaborating Centre)
4.1.3.6 Lot Testing for RDT
4.1.3.7 Lot Testing for Drugs/Medicines
4.1.3.8 PIR among medtechs/ microscopists
4.1.3.9 ReMiDi (Remote Microscopic Diagnosis)
Quality assurance of RDT services

4.1.3.10 TOT of DOH validators on RDT (for RHU plus Hospital MT) arrival
4.1.3.10.1 Orientation of RHU, Public Hospitals and Private hospitals (25%) on
RDT QA (c/o DOH-RO CHD validators)
4.1.3.10.2 Conduct validation visits of RDT workers at various levels
QA for Case Management and Treatment

4.1.3.11 Conduct TES in designated sites every 2 years
4.1.3.11.1 Conduct drug quality testing c/o Collaborating Centre
4.1.3.11.2 QA Product Testing

4.1.3.11.3 Conduct malaria mortality review (as needed)
4.1.3.11.4 On-site validation of treatment compliance (c/o quarterly monitoring visits)
Strategy 4.2 Maintain high quality and effective vector control measures
4.2.1 Provide equipment/supplies for bioassay and susceptibility testing
4.2.2 Conduct bioassay test (per Region)
4.2.2.1 Conduct bioassay tests on used LLIN
4.2.2.2 Batch quality testing for LLINs
4.2.2.3 Conduct bioassay test in post spraying operations in selected
areas
4.2.3 Conduct susceptibility test (18 Sentinel Sites every two years.)
Strategy 4.3 Strengthen malaria case surveillance and response systems in support of
malaria elimination according to the Malaria Surveillance and Response Strategy
4.3.1 Map-out/inventory of existing PESU/ MESU.
4.3.2 Orient MESU staff on PIDSR and Malaria Surveillance and Response
Strategy together with surveillance, M&E, and supervision
4.3.3 Support improvement of quality of disease reporting through PIDSR
4.3.4 PIDSR Reporting (morbidity/mortality cases) in all provinces
4.3.5 Investigate and respond
4.3.6 Mapping and monitoring of known foci for transmission and annual
classification/ reclassification
Strategy 4.4 Maintain effective Malaria Program monitoring and evaluation systems
4.4.1 DOH-CO semi-annual field monitoring
4.4.2 DOH –RP quarterly field monitoring
For Palawan
4.4.2.1 Establish external field monitoring team for Palawan
4.4.2.2 Conduct field monitoring on quarterly basis
4.4.2.3 Feedback/Planning Meeting with Palawan
National
4.4.3.1 PIR
4.4.3.1 National with ROs
4.4.3.2 DOH-ROs with Province/Municipalities
4.4.3.3 Province with Municipalities
4.4.3.2 Annual National Malaria Program Report
4.4.3.3 Mid-Term Evaluation
Operational Research
4.4.4.1 Develop, review and update operational research agenda for the Malaria
Program
4.4. 4.2 Early candidates for special studies and/or research (subject to operational
research workshop and agenda)
4.4.4.2.1 For Palawan
a. FGD
b. OR on MDA
i. Protocol Development
ii Drug Registration
iii Clinical Trial to test safety and efficacy

iv Possible pilot in circumscribed island setting
v Possible MDA roll-out (subject to trial and pilot outcomes)
c. Trial of new insecticide (e.g. non-pyrethroid, long-acting pyrethroid)
d. OR on screens in market place
e. OR/Trial on spraying of outside walls
4.4.4.2.2 Prevalence Survey in 6 other endemic provinces (ARMM, Sultan Kudarat,

Davao Norte)
4.4.4.2.3 Other Surveys/Special Studies
a. BUS
b. Health Facility Survey
c. Behavioural studies in children aged 5 years and 6-14 years
4.4.4.3. Annual Malaria Research Forum
4.4.4.3.1 National
4.4.4.3.2 Regional

Annex 4

Annex 5

Annex 6
Monthly Malaria Record
Year: Municipality: Province: Region:
Number of cases
Barangay/Sitio Pop Houses
Total
May
Aug
Sep
Nov
Dec
Feb
Mar
Jan
Jun
Oct
Apr
Jul
Total

Annex 7
Procedure for Staining Blood Films Using Giemsa Stain
Giemsa is a differential stain composed of methylene blue and eosin. The nucleus is stained red
and while the cytoplasm is blue. Blood smears can be stained singly or by bulk using 3% for
regular staining or 10% Giemsa stain solution in pH7.2 buffered water for rapid staining.
Materials:
 Giemsa Stock Solution  Buffered water (pH 7.2)
 Methanol  Pasteur pipettes
 Graduated Cylinder  Drying rack
 Staining trough  Tap water
 Timer
Steps Batch staining Individual staining

1 Fix the thin film individually by dipping Fix the thin film individually by dipping it
it briefly in methanol. Avoid fumes of briefly in methanol. Avoid fumes of methanol
methanol from reaching the thick film. from reaching the thick film. Let it dry.
Let it dry.
2 Arrange blood films in the staining jar Dehemoglobinized the thick blood film using
tap water.
3 Prepare 3% Giemsa stain solution by Dry the blood film
mixing 3 ml Giemsa stock solution
into 97 ml of buffered water (pH7.2).
Mix the solution gently.
4 Pour the 3% Giemsa solution gently Prepare 10% Giemsa stain solution by
into the staining jar. Make sure every mixing 9 drops of Giemsa stock solution to 3
slide is under the stain solution. Keep ml of buffered water (pH7.2).
the jar away from sunlight
5 Wait for 30 to 45 minutes for staining Place the dry blood film in the staining rack.
and dehemoglobization.
6 Pour clean tap water into the through Flood the smear with 10% solution and wait
to float off the iridescent scum and for 5 to 15 minutes.
wash it off from the jar.
7 Immerse the jar in a vessel with clean Gently pour tap water to float off the scum
tap water. and wash it off from the slide.
8 Rinse slide briefly and gently under Lift the slide when all the scum is washed off
running tap water. and gently rinse in tap water.
9 Arrange the slide in a drying rack face Dry the slide in the rack face down.
down
10 Air dry or blow dry Examine the slide when completely dry
11 Examine the slide when completely
dry

Annex 8
Computation of Logistics
Anti-malaria Drugs
Specifications: Fixed dose combination containing 20 mg arthemether and 120 mg lumefantrine per
tablet.
Computation of AL Requirement
Presentations of AL Notes:
(A) Box of 30 blister packs If Pf cases is not disaggregated by
(B) Blister packs age then make an assumption that:
Blister pack of 24 for age group >13 years 68% =>13 years old
Blister pack of 18 for age group 9-13 years 12% = 9-13 years
Blister pack of 12 for age group 4–8 years 12%= 4-8 year
Blister pack of 6 for age group 6months to 3 years 12%= 6 months – 3 years
(C) Number of Pf cases by age group
>13 years old Lead time represent delay from
9-13 years purchase order to delivery of goods.
4-8 year It is adjustable.
6 months – 3 years
(D) Buffer stock = 25% of C In Zero- Malaria and Malaria- Free
(E) Lead time = 30% of C Provinces the standby stock level is
10 blister packs consisting of 4 blister
packs of 24 and 2 each for other age
group for each health facility. This will
Computation per age group entail huge inventory cost considering
the number of health units and short
AL Requirement (Box) =((C+D+E)÷30) – F expiration of medicine. Mechanism
must be devised by the province to
Summary of Annual AL Requirement store the medicine in strategic
Box of 30×24 blister packs= _____ location ideally with less than one
Box of 30×18 blister packs= _____ hour travel time. Medicines must be
Box of 30×12 blister packs= _____ accessible 24/7.
Box of 30× 6 blister packs= _____ Blister packs can be open to adjust for
the total tablets needed by the patient
Add required standby stock for Zero Malaria, Malaria Free in situation where the appropriate
Provinces and DOH retained hospitals. blister pack is out of stock.
Tablets from different blister packs
have the same milligram content of
active ingredients per tablet.

Specification: Chloroquine 250 mg tablet(150 mg base)
Packaging Specification: Box of 100 tablets in blister pack of ten tablets
Expiration date: 2 years
Computation Notes
A= Box of 100 tablets in 10 blister packs Standby stock level for Zero
B= 10 (Number of tablets to treat a case) Malaria, Malaria Free Province
C= Total number of Pv, Pm and PO and DOH retained hospital is one
D= Buffer stock = 25% of C box each.
E= Lead time = 30% of C
F= Current Stock Level (in boxes)
G= Standby stock for Zero-Malaria, Malaria-Free
Province and DOH Retained Hospital
Computation of annual requirement
A(box) = ((C+D+E)×0.1)+G - F
Primaquine tablet 26.3 mg (15 mg base) as diphosphate

Box of 100 tablets in blister pack of 10 tablets
Computation of Primaquine requirement Note:
A= Box of Primaquine requirement Standby stock level for Zero
B= Total Pf and Pv cases × 3 Malaria, Malaria Free Province
C= Total Pv and Po cases × 14 and DOH retained hospital is two
D = B+C boxes each.
E= Buffer stock = 25% of D
F= Lead time = 35% of D
G= Current Stock Level (in boxes)
H= Standby stock for Zero-Malaria, Malaria-Free
Computation of annual requirement
A(box)= ((D+E+F) × 0.1) + H - G

Quinine 325 mg (300 mg base) tablet as sulfate
Packaging Box of 10 blister packs 10 tablets
Computation of requirement Note:
A = box of Quinine tablets Quinine tablet is distributed to
B= Total Pf cases × 10% health facilities with physicians
C= B×30 tab per case trained in management of severe
D= Buffer stock = 25% of C malaria.
E = Lead time = 35% of C
F = Current stock level (in box) Standby stock level for Zero
G= Standby stock for Zero-Malaria, Malaria-Free Malaria, Malaria Free Province
Province and DOH Retained Hospital and DOH retained hospital is three
(3) boxes each.
A(box)= ((C+D+E) × 0.1) + G - F
Quinine Ampoule
Specifications:
Quinine 100mg/ml as hydrochloride in 1 ml ampoule
Box of ten (10) ampoules
Expiration: 2 years
A = box of Quinine ampoule Quinine ampoule is distributed to
B= Total Pf cases × 10% health facilities with physicians
C= B× 20 ampoule per case trained in management of severe
D= Buffer stock = 25% of C malaria.
Province and DOH Retained Hospital and DOH retained hospital is
three (3) boxes each.
A(box) = C+D+E+G - F

Artesunate Ampoule
Specification: 60 mg artesunic acid per ampoule with diluent of 5% sodium bicarbonate
solution
Packaging: 1 box of 10 ampoule and 10 diluents
A = box of Artesunate ampoule Artesunate ampoules are
B= Total Pf cases × 10% distributed to health facilities with
C= B× 8 ampoule per case physicians trained in management
D= Buffer stock = 25% of C of severe malaria.
Province and DOH Retained Hospital and DOH retained hospital is four
(4) boxes each.
A(box) = C+D+E+G - F
Artesunate Suppository
Specifications:
Active ingredient:
Preparation: 100 mg and 400 mg rectal suppository
Packaging: Box of 10 rectal supp
Expiration: 2 years
Computation of Requirement Notes:

A = box of Artesunate rectal suppository
B= Total Pf cases × 10% Standby stock level for Zero
C= Buffer stock = 25% of B Malaria, Malaria Free Province
D = Lead time = 35% of B and DOH retained hospital is one
E = Current stock level (in box) box of 100mg supp and one box of
F= Standby stock for Zero-Malaria, Malaria-Free 400 mg supp.
A=B+C+D-F
Divide A for proportion of 100 mg and 400 mg

suppository

Annex 9
Monitoring and Evaluation Plan Template for Municipal Level

Strategy/Activity Target Indicator Data Date of Resources Cost
Number Number Source Collection needed

Annex 10
Procedure for Susceptibility Test
The purpose of the Insecticide Susceptibility Test is to determine the susceptibility/resistance

profiles of vectors against currently used insecticides. The DOH-Regional Office must conduct
Susceptibility Test using the WHO standard test kit in coordination with the Collaborating Center.
At least four sites (two sites per year every two years) per region will be chosen for insecticide
susceptibility testing.
Procedure for Insecticide Susceptibility Test using standard WHO Tube Bioassay
1. Insert a 12x15 cm sheet of clean white paper into each of the holding tubes (green-dotted).
The paper should be rolled into a cylinder to line the wall of the plastic tube and fastened in
position using a silver spring-wire clip. A slide unit is attached to one end of each holding tube.
2. Collect carefully adult female mosquitoes using a manual aspirator. Mosquitoes should be
collected in lots of 10 or less.
3. Introduce batches of 20 mosquitoes into each holding tube through the filling hole of the slide
units. Close the slide. Prepare five replicates with each type of insecticide-impregnated paper and
three replicates for the oil-treated control paper.
4. Once the mosquitoes have been transferred, the slide unit is closed.
5. The holding tubes are set in an upright position with the screen-end up for a 1-hour pre-test
holding period for acclimatization of the mosquitoes.
6. At the end of this time, any dead and/or damaged mosquitoes are removed and replaced.
7. Three control tubes (green-dotted) are prepared by lining with a sheet of oil-impregnated paper
fastened using silver spring-wire clip. Five exposure tubes (red-dotted) are lined with a sheet of
insecticide-impregnated paper fastened in position using copper spring-wire clip.
8. Hands should be thoroughly washed with soap and water after handling the impregnated paper
of each insecticide to avoid contamination of the papers of the other insecticides.
9. The control/exposure tubes are attached to the corresponding vacant screw-top on the slides.
10. With the slide unit open, the mosquitoes are blown gently from the holding tubes into the
control/exposure. Once all the mosquitoes are in the control/exposure tubes, the slide unit is
closed.
11. The holding tubes can be detached and set aside.
12. Control/Exposure tubes (with the slide unit) are set in a vertical position, with the screen-end
up, under conditions of diffused illumination and adequate humidity.
13. Record the number of mosquitoes knocked down in each control and exposure tubes every 5
minutes for 60 minutes in susceptibility data sheets. The relative humidity and temperature are
also recorded during the susceptibility test.
14. Attach the holding tube into the slide at the end of the 1-hour exposure period.
15. Open the slide and the mosquitoes are blown back into the holding tubes. The control/
exposure tubes are detached from the slide unit.
16. Set the holding tube vertically so that it stands on the slide. Provide cotton pads/balls soaked
in 10% sugar solution and place moist towel onto the screen of the tubes.
17. Keep the holding tubes for 24 hours in a secluded, shaded place where the temperature does
not exceed 30°C and protected from ants.
18. At the end of the 24-hour post-exposure, the number of dead mosquitoes is counted and
recorded on the forms provided. Affected mosquitoes that are unable to walk should be counted
as dead.

19. At least 3 replicates will be conducted. 20. Calculation of Susceptibility Test Mortality
Test mortality = Total number of dead mosquitoes x 100

Total number of mosquitoes exposed
A similar calculation should be made in order to obtain a value for the control mortality.
1) Where the test control mortality is between 5% and 20%, the final percentage mortality will be
corrected using Abbott’s formula:
Corrected mortality = (% test mortality - % control mortality) x 100
(100 - % control mortality)
2) If the control mortality is below 5%, no correction is necessary. If the control mortality is
above 20%, the tests must be discarded.
Interpretation of the susceptibility test results

– 100% mortality: indicates susceptibility to the insecticide
confirmation

Annex 11
Procedure for Bioassay Test
The purpose of Bioassay Test is to determine the residual effectiveness of new and currently
used insecticides in vector control; and to evaluate quality of vector control operations.
Wall Bioassay
1. Affix the WHO bioassay cones onto the sprayed walls using adhesive sponge tape at heights
of 2m, 4m and 6m. For the control, affix the cone onto a piece of clean cardboard.
LLIN Bioassay
Affix the cones onto 5 different positions: (1) bottom of one of the side panels, (2) 25 cm from the
bottom of next side panel, (3) center of the roof panel, (4) 50 cm from the bottom of the third side
panel, and (5) top side of the last side panel. Exclude position (1) as it may be exposed to
excessive abrasion in routine use. For the control, affix the cone onto a piece of untreated net.
3. Transfer 10 wild caught female Anopheles vector mosquitoes into each cone using a sucking
tube; making sure that the end of the tube does not touch the treated surface. Cover the top
opening of the cone with absorbent cotton.
4. Record the temperature and relative humidity before, during and after the test.
5. Expose the mosquitoes for 30 minutes for Wall Bioassay Test (3 minutes for the LLIN bioassay
test). 6. After the exposure period gently transfer the mosquitoes, including those knocked down,
into the styro cup covered with net cover with small holes in the side. Plug the hole with cotton
ball to prevent mosquitoes from escaping.
7. Label the styrocups accordingly.
8. Mark the position where the cones were fastened using a pentel pen marker.
9. Count and record the number of dead or knocked down after 1 hour.
10. Provide cotton pads/balls soaked in 10% sugar solution and place a pad of moist towel onto
the screen of the styro cup.
11. Keep the styro cups for 24 hours in a secluded, shaded place, where the temperature does
not exceed 30 °C. The tubes should be protected from ants by placing them on a platform
standing in a pan of water.
12. Count mosquito mortality after 24 hours. Mosquitoes that are unable to walk due to missing
limbs (2 or more), mosquitoes that are unable to fly due to tears in membranous wings, and the
like will be counted as mortality. Mortality of the vector mosquitoes from the bioassay test should
not be lower than 80%. If the result falls below 80%, another round of spraying cycle is
recommended.

Calculation of Susceptibility Test Mortality
Test mortality = Total number of dead mosquitoes x 100

Total number of mosquitoes exposed
Where the test control mortality is between 5% and 20%, the final percentage mortality will be
corrected using Abbott’s formula:
Corrected mortality = (% test mortality - % control mortality) x 100

(100 - % control mortality)
If the control mortality is below 5%, no correction is necessary. If the control mortality is above
20%, the tests must be discarded.
Interpretation of the susceptibility test results
– 100% mortality: indicates susceptibility to the insecticide
confirmation

Annex 12
Procedures for Indoor Residual Spraying

Planning IRS operation
 Regular IRS operation is two months before the peak of transmission season. It is when
the vector population is naturally down and operation will not be hampered by rains.
Availability of funds usually delays the operation. Assuring availability of funds months
ahead will ensure timely IRS operation. Table below shows computation of cost for IRS
operation for one cycle or once a year operation. Follow the same computation for the
second cycle by substituting the data of the target number of houses and duration of
spraying.
Computing cost of IRS operation (one cycle)

Cost Computation of one cycle Indoor Residual Spraying (IRS) Operation
Computation of IRS Labour Cost Notes
Let:
A = Number of Barangay for IRS
B = Number of houses for IRS
C = Duration of operation (in days)
D = Number of sprayed houses per day to finish within C= IRS must be finish before the start
B÷C of rainy season.
E = Average daily output of Spray Squad = 40 IRS in one barangay must be
F = Number of spray squad needed = D÷E finish within 10 days or less.
G = No. of Squad Leader (Sql) required = F Deploy more squad to finish within
H = No. of spray man (Spm) needed = F × 4 10 days.
I = Rate per day of Spm Salary rates and allowances
J = Rate per days of SQL depend on the prevailing rate in
K= Rate per day of transport allowance and per diem the region.
L= Total salary of Spm = I×H×C Computation is for one spraying
M = Total Salary of Sql= J×H×C cycle.
O = Total allowance and per diem=(F+C)×C×K
P = Total Labour cost(one cycle)=L+M+O
Computation for cost of insecticide
Let
Q = Number of houses for IRS= NO. of sachet of
insecticide One house will consume one
spray can load of insecticide or
shortly one load.

Follow manufacturer’s direction in
R = Cost of one load the number of sachet per spray
can load.
S = Total cost of insecticide = A×B
Computation of Total cost of one cycle IRS operation
Let
T = Incidental Cost (%)
U = Total spraying Cost(one cycle)=(P×T)+P+S Percentage of incidental cost
varies.
Spraying Itinerary and implementation

 Itinerary must be ready before spraying for ease of movement of the team. Start from the
most distant barangay moving towards the centre. Consider road access to minimize
movement of team and equipment. Sketch map is necessary for operation and it facilitates
monitoring. Make a sketch map or update the old one during operation.
 Preparing the household

o Inform the household of the spraying schedule and the purpose of spraying, giving
them time to prepare and vacate the house.
o Inform the house occupants that they must leave the house before spraying.
o Areas occupied by sick people who cannot be moved must not be sprayed.
o Take out all household items, including water, food, cooking utensils and toys from
the house.
o Move, cover or take out furniture to allow easy access in spraying walls. Items that
cannot be moved should be well covered.
o Keep or cage pets and domestic animals away from the house.
 Preparing the Equipment

o Examine the sprayer to ensure that all parts are complete, assembled correctly,
and in good working condition.
o Try out the sprayer by first using clean water to ensure that the equipment does
not leak.
o Calibrate the nozzle tip. Fill the spray can with water and pump to 55 psi. Open the
trigger for one minute and collect the discharge. It must be 360 ml in one minute.
Change the nozzle tip if the discharge is more than 798 ml.
o After ensuring that the sprayer works, begin the task at hand
o Each spray person must bring spare parts, gasket and tools for repair of spray can.
 Mixing of Insecticide
o Use proper personal protective clothing and devices (PPCD) - elbow length rubber
gloves, goggles for eye protection, mask, and cover-all.

o Always read and follow the instructions of the manufacturer before mixing the
insecticide.
o Pour the correct volume of water as indicated in the manufacturer’s instructions
inside the sprayer.
o Add the insecticide into the water-filled spray tank.
o Pump the open tank to mix the insecticide.
o Close the tank and pump until the pressure gauge reads 55 psi.
o Agitate the tank intermittently while spraying to prevent settling of insecticide at
tank bottom.
o Pump more air if the pressure falls below 45 psi.
 Actual Spraying of House
o Move furniture, wall decors and other belongings away from the wall preferably out
of the house or into the middle of the room and cover them.
o Close the windows so that the inner side will be sprayed.
o Start spraying in the innermost room starting at the right side of the door moving
clockwise ending at the left side of the door.
o Spray the underside of the tables and furniture and other surfaces where mosquito
can rest.
o Open the windows and spray the eaves and outside part of the house not exposed
to sunlight or rain.
o Spray underneath the floor in elevated houses.
o Spray other structures where people sit during the night.
 Procedures After Spraying
o Advise household occupants to stay outside until spray is dry (at least 30 minutes
to 1 hour).
o Sweep or mop floors before allowing the children or pets back to the house;
o Do not clean or wipe the sprayed wall.
o Advise households to prevent mosquito bites that carry malaria
 Maintenance of Equipment at the end of each day

1. De-pressurize the tank and pour out any remaining water into pit latrines or into a
pit away from water sources.
2. Fill the tank half-full with clean water.
3. Replace the lid.
4. Shake the tank so all inside surfaces are washed.
5. Pump up to 3 bar pressure.
6. Spray water through nozzle.
7. De-pressurize the tank
8. Unscrew the strainer housing and wash the strainer.
9. Reassemble the strainer.
10. Remove the nozzle tip and wash; Use soft toothbrush to remove insecticide and
dirt at nozzle tip. Do not use hard object to clean nozzle tip.
11. Re-fit the nozzle.
12. Clean outside of the tank.

13. With lid open, turn tank upside down, open the on/off valve and let the water drain
out of the hose and lance.
14. Ensure the lance is parked to protect nozzle when not in use.
15. When storing the sprayer for a long period, hang it upside down with lid open to
allow air circulation
 Safety Precautions
o Wear PPE while handling insecticides.
o Do not eat, drink or smoke while spraying.
o Wash hands and face with soap and water after spraying and before eating,
smoking or drinking.
o Shower or bathe at the end of day’s work and change into dry clean clothes.
o Wash coveralls and other protective clothing with soap and water at the end of
each working day.
o If insecticide gets on the skin, wash off immediately with soap and water.
o Change clothes immediately if they become contaminated with insecticides.
o Inform immediate supervisor at once, if you do not feel well.
o Do not allow a spray person to work more than 4 consecutive days a week.
o Require each spray person to undergo a yearly medical check-up.
 Disposal of excess insecticide and empty packaging
o Put the washings of insecticide into pit latrines.
o Never pour the remaining insecticide into rivers, pools or drinking water sources.
o Return empty sachets/packaging to the supervisor/squad leader.
o Never re-use empty insecticide containers.
o Dispose surplus insecticide in pit latrines or bury them away in areas from water
sources.
o Never wash materials and equipment used in treatment in rivers, streams or ponds
as insecticides are toxic to fishes, shrimps and animals.
o Destroy empty insecticide containers to prevent reuse for other purposes.
Supervision
 Squad leader (SqL) is the immediate supervisor of the spray men. Close supervision is
important to achieve the desired quality of spraying. Squad leaders must be observant on
the speed of traverse, dripping walls and leaks in the spray can. Errors in spraying must
be corrected immediately and spray man must always be motivated to apply the
insecticide uniformly with minimum supervision.

Reporting
 Spray men make a report of daily accomplishments and submit it to squad leader (SqL)
at the end of each day. The SqL summarizes reports daily and another summary report
for each barangay. The report is submitted to the municipal malaria coordinator (MMC).
Summary report will be prepared by the MMC at the end of spraying cycle and forward a
copy to the Provincial Malaria Coordinator (PMC).
 Secondary data can be generated from these reports like IRS coverage, refusal rate and
some qualitative data like reason for refusal. The report can also be the source document
for updating demographic record of the barangay.
Integration with other intervention
 Active case detection and health education must always be with IRS to reduce the parasite
pool in the community. Health messages must be “sleep inside mosquito net every night
and to seek treatment immediately”. Another person may be added temporarily to spray
team during the first day of IRS in a barangay to conduct house visits and seek community
members with malaria symptoms for blood test and treatment. This will remove parasite
reservoir among human with symptoms.
Monitoring the effect of IRS
 The municipal malaria coordinator should conduct monthly monitoring in areas where IRS
has been done. They should be validated by the Provincial Malaria coordinator.
 Monthly malaria record of barangay is useful for monitoring the effect of IRS. The month
when IRS took place can be shaded (Annex16) and the cases 12 months before and 12
months after can be compared. It is expected that reduction of cases will be observed
after IRS. Problem exists if there is no reduction of cases after IRS. It can be insecticide
resistance, low coverage and poor quality of spraying, removal of insecticide deposit by
householders or outdoor biting of the vector. Investigation is needed and evidence must
be gathered to identify the root cause of the problem.

Annex 13
Adjunct Vector Control Methods
1. Larval source management
o Vector control of choice for malaria-free provinces

o Seeding and re-seeding of stream/breeding site with larvivorous fish
o Mosquito larva is natural food for the fishes. Gambusia sp and Poecilia sp are small in
size, reproduce rapidly and voracious larvae eaters. They can be raised in tanks/drums
and reseed the streams where mosquitoes breed.
o Biological control with Bacillus thuringensis
o Bacillus thuringensisis bacteria poisonous to mosquito larvae and other insects.
Bacillus thuringensis is produced in the laboratory is mixed with carrier (sawdust or
rice hull) and broadcast to breeding site.
2. Breeding site management
o Environmental management
o Stream bank clearing to increase flow of water and expose the larvae to
larvivorous fish
o Clearing of vegetation along the stream to expose the stream to sunlight and
to remove resting areas of adult mosquitoes
o Environmental modification
o Automatic siphon flush and drown the larvae
o Pipe draining usually done in coastal areas directed against mosquitoes breeding
in brackish water.
3. Zoo prophylaxis
o Large animals like cattle and carabao are tied near the houses to divert mosquito
feeding away from humans.
4. Space Spraying
o Fogging or Ultra Low Volume application

o Use during extreme emergency
o Effect do not last longer than one hour
o Need special equipment
o Very expensive
5. Insecticide treated materials
o Treatment of curtains or ordinary mosquito nets in case LLIN is not immediately

available

Procedure for Treatment of Mosquito Net
Materials
1. Mosquito net
2. 200 ml to 500 ml water Notes:
3. Insecticide tablet WT formulation One family size polyethylene mosquito net will
4. Big plastic bag need 200 ml to 500 ml of water to moisten it
5. Wide mouth 1L PET bottle evenly.
Procedure
1. Put 200 ml to 500 ml of water and Avoid “EC” and “SC” insecticide formulation
insecticide tablet in 1 L PET bottle and because the carrier will damage the
agitate until the tablet is fully dissolved. polyethylene material of the net.
2. Place the mosquito net inside the big
plastic bag and pour the insecticide
solution. Wear PPE while treating mosquito nets.
3. Squeeze the bag to remove air.
4. Hold the lid of plastic bag tightly.
Remind mosquito net owner to:
5. Put on a table or flat surface and knead
to evenly distribute the insecticide  Avoid frequent washing
solution.  Do not use bleach and detergents in
6. Stand for a few minutes to allow washing
excess solution to collect at the bottom  Do not dry in the sun after washing
of plastic bag.  Sleep inside mosquito net every night
7. Remove the treated mosquito net and
air dry.
8. Return the mosquito net to the owner
and remind to “sleep inside mosquito
net every night”.
List of Insecticides for Treatment of Conventional Mosquito Nets
Table 3.23 List of WHOPES Approved Insecticide for Mosquito Net Treatment
Dosage
Insecticide Formulation
(in mg/m2 of net)
Alpha-cypermethrin SC* 10% 20 – 40
Cyfluthrin EW** 5% 50
Deltamethrin SC 1% 15 to 25
WT*** 25%
WT 25% with binder
Etofenprox EW 10% 200
Lambda-cyhalothrin CS*** 2.5% 10-15
*Suspension Concentrate **Emulsion oil in water ***Water dispersible tablet
****Capsule Suspension

Annex 14
Reporting Forms

Annex 15
Evaluating the effect of IRS or vector control activities

Shaded months show the date of IRS. Compare the cases 12 months before and 12 months after IRS. It
is expected that application of intervention will reduce the number of cases in the succeeding months.
Barangay Abante, Population 700 Houses 134

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2014 3 5 2 0 3 7 12 5 3 1 1 0
2015 1 2 1 4 6 9 2 6 2 7 1 2
2016 0 2 2 0 0 4 3 4 2 0 0 1
2017 3 5 2 6 3
Comparison
Month of IRS from table above is April 2015

Number of cases 12 months before IRS (April 2014 to March 2015) =36
Number of cases 12 months after IRS (May 2015 to April 2016) = 39
Conclusion: IRS has no effect in the number of cases based on the table above.

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MALARIA MANUAL OF

The country’s program implementation, in line with the FOURmula One

National Malaria Control and Elimination Program Manual of Operations

Asian Collaborative Training Network for Malaria Inc. (ACTMalaria)

National Malaria Control and Elimination Program Manual of Operations i|Page

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National Malaria Control and Elimination Program Manual of Operations v|Page

strategy to prevent re-introduction of malaria and integrated malaria control method to

National Malaria Control and Elimination Program Manual of Operations 1|Page

Fig. 1.1 Malaria Paroxysm

National Malaria Control and Elimination Program Manual of Operations 2|Page

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4 Malaria Status of Provinces

Table1.1 Category List of Provinces

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5 Vision, Goal and Objectives

Vision : A Malaria–Free Philippines by 2030

Mission : Further accelerate malaria control and transition towards

Goal : By 2022, to reduce malaria incidence in the Philippines by 90%

Objective 1 (Universal Access) – To ensure universal access to reliable diagnosis,

Objective 2 (Governance and Human Resources) – To strengthen governance

Objective 3 (Health Financing) – To secure government and non-government

Objective 4 (Health Information and Regulation) – To ensure quality malaria

National Malaria Control and Elimination Program Manual of Operations 6|Page

Overall Policy Direction

National Malaria Control and Elimination Program Manual of Operations 7|Page

Strategy 1.3 Implement responsive malaria interventions among identified vulnerable

National Malaria Control and Elimination Program Manual of Operations 8|Page

National Malaria Control and Elimination Program Manual of Operations 9|Page

Fig 2.1 Interplay of factors in the environment determines malaria transmission.

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Development of the parasite from gametocytes to sporozites takes 9 to 12 days in the

Table 2.1 Selected Characteristics of Malaria Vectors in the Philippines

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Table 2.2 Location and Stages of Parasite Life Cycle

Human RBC Gametocytes (male &

Zygote One incubation interval (25-35 days)

Gametocytes (male & Gametogony

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Table 2.3 Number of Offspring from a Single Parasite

Sporogony Schizogony(in humans)

Pv ~1000 10,000 12-14

Pm ~1000 15,000 8-12

Po ~1000 15000 6-12

4 The Human Host

Lack of immunity predisposes individuals to development of severe malaria. People living in

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Health Service Providers

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Malaria elimination is the interruption of local mosquito-borne malaria transmission resulting

Receptivity is the ability of the ecosystem to allow transmission of malaria.

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1.1 Malaria Elimination Strategy

Program Policy Directions in transitioning from control to elimination

 Focused application of diagnostic and treatment and vector control measures

 Quality assured malaria interventions