WHO malaria terminology

WHO malaria terminology 2021 update Global Malaria Programme

Global Malaria Programme WHO malaria terminology 2021 update WHO malaria terminology, 2021 update ISBN 978-92-4-003840-0 (electronic version) ISBN 978-92-4-003841-7 (print version) This document was first published in 2016 with the reference number WHO/HTM/GMP/2016.6 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. iii Contents Drafting Committee iv Acknowledgements v Introduction 1 Process 1 The special case of “malaria case” 3 Glossary 6 Bibliography 26 Archived terms 29 iv DRAFTING COMMITTEE Members Professor Andrei Beljaev Russian Academy of Postgraduate Medical Training, Moscow, Russian Federation Professor Graham V. Brown Melbourne School of Population and Global Health, University of Melbourne, Australia Dr Kamini Mendis Independent Expert, Colombo, Sri Lanka Dr José Najera Independent Expert, Crans de Celigny, Switzerland Dr Tanya Russel Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia Dr Rick Steketee U.S. President’s Malaria Initiative (PMI), CDC and USAID, Washington, United States of America Professor Graham White Entomology and Nematology Department, University of Florida, Gainesville, Florida, USA WHO Secretariat Dr Pedro Alonso Director, Global Malaria Programme Dr Andrea Bosman Coordinator, Director Office, Global Malaria Programme Former members Dr Trenton Ruebush Independent Expert, Alexandria, Virginia, USA W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e v ACKNOWLEDGEMENTS The invaluable support provided by Ms Mar Velarde, ISGlobal, Malaria Eradication Scientific Alliance, in the desk review for the drafting committee is gratefully acknowledged. The contributions of all members of the drafting committee are recognized. Their precision, careful attention and timely, precious feedback were instrumental for completion of the work. The external survey was ably managed by Mr Ryan Williams, WHO Global Malaria Programme, following the indications of the drafting committee, and all inputs and the analysis of the survey results were efficiently compiled by Ms Silvia Schwarte, WHO Global Malaria Programme. The inputs received from over 20 institutions and groups are greatly appreciated. These included the Asia–Pacific Malaria Elimination Network; the Foundation for Innovative New Diagnostics; the Gates Foundation malaria programme; IVCC (Liverpool School of Tropical Medicine); the Malaria Elimination Group, University of California, San Francisco; Medicines for Malaria Venture; PATH Malaria Control and Elimination Partnership in Africa; the Centers for Disease Control and Prevention (USA); and the President’s Malaria Initiative (USA). Support was also provided by the Roll Back Malaria (RBM) Case Management Working Group, the RBM Monitoring Evaluation Reference Group, the RBM Vector Control Working Group, the Vector Control Advisory Group (WHO Global Malaria Programme), WHO regional malaria advisers and the WHO Technical Expert Groups on Antimalarial Drug Resistance and Containment, Malaria Chemotherapy, Surveillance, Monitoring and Evaluation and Vector Control. Input is also acknowledged from numerous WHO collaborating centres, for: Malaria; Surveillance of Antimalarial Drug Resistance; Evaluation of New Insecticides against Vectors; Ecology, Taxonomy and Control of Vectors of Malaria, Filariasis and Dengue; Malaria Diagnosis; Malaria Control, Elimination and Eradication; Clinical Management of Malaria; Geospatial Disease Modelling; Prevention and Control of Malaria; and Early Warning Systems for Malaria and Other Climate-sensitive Diseases. Dr Rick Steketee, Chair of the Drafting Committee provided guidance throughout the planning and review process, and Dr Andrea Bosman served as the secretariat of the committee. The work was funded as part of a contribution from the Bill & Melinda Gates Foundation to the WHO Global Malaria Programme. vi W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 1 In recent years, there has been a proliferation of new terms in relation to malaria in the scientific literature, the media and technical reports and also of terms with new or modified use and meaning. These changes stem from renewed global interest in malaria elimination and eradication, increasing access to scientific and technical information and faster translation of research findings into evidence-based policies. This proliferation has raised certain difficulties: • Some new terms are used in several different ways. • Several similar terms have the same meaning. • Some terms used to describe malaria interventions have different meanings in other public health programmes. The situation is generating increasing confusion and misunderstanding, not only in the scientific community and funding agencies but also among public health officials responsible for malaria programmes and policy-makers in malaria-endemic countries. WHO has periodically reviewed the terminology of malaria; however, the latest official publication on this topic dates back to 1963 (1). Several WHO publications in the past 10 years have included glossaries of terms used in malaria surveillance, control and elimination; however, there has been no comprehensive review of the terminology of malaria since the work of the drafting committee in 1963. On this basis and on the advice of the Malaria Policy Advisory Committee1 at its seventh biannual meeting in March 2015, the WHO Global Malaria Programme (GMP) Secretariat decided to update the WHO terminology of malaria as a glossary. PROCESS First, a desk review was conducted of terms used in programmes for malaria elimination and eradication that have different definitions and uses. The glossaries and lists of terms and definitions reviewed were those in: • all WHO publications on malaria since 1995, in addition to those in Terminology of malaria and of malaria eradication (16 documents) (1); 1 Now the Malaria Policy Advisory Group (MPAG). Introduction Medical language must be adaptable so that it can keep pace with the constant increase of our knowledge and with the continual revision and evolution of our concepts. Terminology of malaria and of malaria eradication. WHO; 1963 2• publications by other WHO departments, such as “preventive chemotherapy for neglected tropical diseases” (16 documents); and • scientific papers with definitions or glossary published during the past 10 years, to identify terms used recurrently that are the same or similar but are given different meanings and also new terms that are given similar meanings (15 publications). The search revealed 292 terms, which were divided into four groups: elimination (50), vector control (69), surveillance (85) and diagnosis and treatment (88); many terms were relevant to both elimination and surveillance. Initial draft definitions were proposed for each term. All 292 terms and their definitions were submitted for discussion to the members of the newly formed Drafting Committee on Malaria Terminology, who were asked to classify them into three groups: • those that were and are still relevant and properly described, to be reviewed to update the language but generally considered “good as they stand”; • those that have been used in the past and have value for historical purposes but are no longer in current use and could be considered for archiving; and • terms that are relevant today but have taken on a new meaning or different use, which should be reviewed and possibly redefined or at least updated so that the definition reflects their current use. After the initial individual reviews, the Committee was convened for a consultation in Geneva on 2–3 June 2015, where the members worked in pairs on all terms and presented the results in plenary for review by the whole committee. The work was refined after the meeting, through e-mail exchanges among Committee members, when a concerted effort was made to simplify the definitions as much as possible. As a result, the recommended definitions tended to be short, and explanatory notes were added. After this extensive work, the Drafting Committee considered that 153 terms were properly described, proposed 38 for archiving and identified 101 terms as requiring additional work. For the 101 terms requiring additional work and external review, WHO set up an online survey to collect expert feedback in a systematic way. A web link was issued to 30 identified institutions or groups (full list in the Acknowledgements), and 47 passcodes (“tokens”) dedicated to institutions or groups were sent to the corresponding lead contacts (e.g. chief executive officers, chairs or co-chairs of working groups and directors), who could recruit additional technical resources from their institution or group to participate in the review by sharing the passcode. The input from the reviewers at each institution or group was recorded as a single response with a single token. To facilitate review and feedback, the 101 terms were grouped into four thematic areas: diagnosis and treatment (32 terms), elimination (28 terms), surveillance (21 terms) and vector control (20 terms). Each term had a draft definition and, when appropriate, an explanatory note. For each term and commentary, the reviewer was invited to recommend: retain (“OK”), reject (“omit”) or amend (“modify”) with a written alternative text. The survey was carried out between 6 and 26 July 2015. Responses were obtained with 25/47 tokens from 20/30 institutions or groups. A total of 1260 entries were received. The external reviewers found that 884 entries were acceptable, recommended 75 entries for archiving and recommended specific modifications for 301 terms. Only five W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 3 terms were marked “OK” by all reviewers: causal prophylaxis, passive case detection, stable transmission, unstable transmission and gonotrophic dissociation. All inputs were reviewed and compiled by the WHO GMP Secretariat, and the suggested modifications were then submitted to the Drafting Committee for review by e-mail exchange. The consolidated result of this work, in the form of a glossary, was then submitted for final discussion to the Malaria Policy Advisory Committee at its eighth biannual meeting in September 2015. The participants also discussed the term “malaria case”, which had generated significant debate among the members of the Drafting Committee and external reviewers. The list of terms and definitions resulting from this process is presented in the glossary below, which is posted online on the WHO website. The WHO malaria terminology document aims to provide clear and concise technical terms and definitions, supplemented by explanatory notes (when required). The document also includes an “archive section” listing those terms no longer in official use. As a general principle, the WHO malaria terminology document should focus on malaria-specific terms only. The document is updated regularly based on input from WHO technical expert groups and review by the WHO Drafting Committee on Malaria Terminology. The process of developing and updating malaria terms for the WHO malaria terminology document is described as follows: 1. Terms in need of revision or new terms to be introduced or discontinued are identified by experts convened by WHO in guideline development groups, technical consultations, evidence review groups and other advisory groups, as well as the GMP Secretariat. Suggested changes are proposed to the Malaria Terminology Committee, along with background and explanations. 2. The proposed terms and definitions are reviewed and refined by the Committee. Based on the inputs received, the Chair of the Committee provides consolidated feedback to the GMP Secretariat, with rationale for the proposed changes. 3. Based on the advice of the Committee and GMP technical staff, the GMP Director finalizes and approves the revisions to the WHO malaria terminology document, after consulting with the Chair of the Drafting Committee in the case of any major changes. 4. The GMP Secretariat shares the final set of revised terms, definitions, explanatory notes and rationale for the changes with the group that originally proposed the terms, as well as with members of the Terminology Committee. THE SPECIAL CASE OF “MALARIA CASE” The most difficult definition for review was that of a “malaria case”. The complexity of defining this term was already recognized when the first WHO terminology for malaria and malaria eradication was published. In that publication, a case was defined as follows: Case. An occurrence or instance of infection or disease. The word is so vague that the type of case should always be specified, as, for instance, a malaria case or a fever case. 4“Case” is defined generally in Dorland’s medical dictionary as follows (2): Case. A particular instance of disease; sometimes used incorrectly to designate the patient with the disease. Malaria control programmes typically report the number of “malaria cases” as the number of people presenting with illness diagnosed as malaria infection, consistent with the above definition of an instance of illness or disease linked to infection. With the transition of a malaria programme to elimination, emphasis is shifted to malaria infections that may remain asymptomatic for long periods and contribute to transmission. In the elimination phase, therefore, the term “malaria case” evolves to apply to both symptomatic and asymptomatic infections. In the current recommendation for parasitological confirmation of malaria when an individual presents with illness that is suspected to be malaria, WHO recommends that all “cases” be confirmed with the available diagnostic tools. As there was no unanimous agreement on the definition or on a proposal to modify the definition of “case” for the transition from control to elimination, the Drafting Committee decided to propose two options to a wider audience to obtain additional comment: Draft definition 1: Occurrence of malaria illness or disease in a person in whom the presence of malaria parasites in the blood has been confirmed by parasitological testing. Note: A malaria case can be classified as suspected, presumed or confirmed and as autochthonous, indigenous, induced, introduced or imported (depending on the origin of infection) or as relapsing. Draft definition 2: Occurrence of malaria infection (symptomatic or asymptomatic) in a person in whom the presence of parasites in the blood has been confirmed by parasitological testing. Note: A malaria case can be classified as autochthonous, indigenous, induced, introduced or imported (depending on the origin of infection) or as relapsing. The results of the external survey, additional review by the Drafting Committee and the advice of the Malaria Policy Advisory Committee showed general consensus for a single definition of “malaria case”, as proposed in this glossary, for surveillance purposes, which would be applicable to various areas in countries, including those for malaria elimination. The definition proposed below reflects the action required for malaria elimination, which is increasingly the aims of all malaria programmes within the Global technical strategy for malaria (2016–2030). It has already been adopted and is in widespread use in malaria elimination programmes, with related terms (e.g. “case investigation”, “index case”, “case follow-up”). It is in line with the requirement that countries report only laboratory-confirmed cases as “malaria cases” and has the advantage of continuity with the definition of the past. Malaria case. Occurrence of malaria infection in a person in whom the presence of malaria parasites in the blood has been confirmed by a diagnostic test W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 5 Note: A suspected malaria case cannot be considered a malaria case until parasitological confirmation. A malaria case can be classified as imported, indigenous, induced, introduced, relapsing or recrudescent (depending on the origin of infection); and as symptomatic or asymptomatic. In malaria control settings, a “case” is the occurrence of confirmed malaria infection with illness or disease. In settings where malaria is actively being eliminated or has been eliminated, a “case” is the occurrence of any confirmed malaria infection with or without symptoms. There is strong consensus that, to reduce confusion, all malaria data sets should include the malaria case definition. References 1. Terminology of malaria and of malaria eradication: report of a drafting committee. Geneva, World Health Organization; 1963 (https://apps.who.int/iris/ handle/10665/39007, accessed 27 September 2021). 2. Dorland’s Illustrated Medical Dictionary. Philadelphia: Elsevier Saunders; 2012. 3. Global technical strategy for malaria 2016–2030. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/176712, accessed 27 September 2021). The strategy was updated in 2021 (https://apps.who.int/iris/ handle/10665/342995). 6adherence Compliance with a regimen (chemoprophylaxis or treatment) or with procedures and practices prescribed by a health care worker adverse drug reaction A response to a medicine that is harmful and unintended and which occurs at doses normally used in humans adverse event Any untoward medical occurrence in a person exposed to a biological or chemical product, which does not necessarily have a causal relationship with the product Note: During malaria interventions, adverse events may be reported following treatment with anti malarial medicines and/or exposure to insecticides. The standard definition in the good clinical practice guidelines of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use refers to pharmaceutical products only. adverse event, serious Any untoward medical occurrence in a person exposed to a biological or chemical product, which is not necessarily causally related to the product, and results in death, requirement for or prolongation of inpatient hospitalization, significant disability or incapacity or is life- threatening aestivation A process by which mosquitoes at one or several stages (eggs, larvae, pupae, adults) survive by means of behavioural and physiological changes during periods of drought or high temperature age group Subgroup of a population classified by age. The following grouping is usually recommended: • 0–11 months • 12–23 months • 2–4 years • 5–9 years • 10–14 years • 15–19 years • ≥ 20 years Note: Reporting on age groups can be modified, as appropriate, to local transmission, whereby certain age groups may be of specific interest (e.g. for passive immunity or assessment of ongoing transmission, 0–5 months and 6–11 months; young migrant work force, ≥ 20–29 years; elderly > 60 years, because of the risk for complications). age, physiological Adult female mosquito age in terms of the number of gonotrophic cycles completed: nulliparous, primiparous, 2-parous, 3-parous et seq. Note: Vector age is typically assessed by age grading instead of days. age-grading, of female adult mosquitoes Classification of female mosquitoes according to their physiological age (number of gonotrophic cycles) or simply as nulliparous or parous (parity rate) Note: Vectors are age-graded mainly to assess the impact of environmental changes (natural or intended for control) on vector populations. In epidemiological studies, age-grading of vectors is used to estimate the mean probability of their survival, a key variable for calculating the basic reproduction number, R0, and vectorial capacity. Glossary W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 7 age-grading, of mosquito larvae Classification of mosquito larvae as instars (development stages) 1, 2, 3 and 4 annual blood examination rate The number of people receiving a parasitological test for malaria per unit population per year Anopheles, infected Female Anopheles mosquitoes with detectable malaria parasites Anopheles, infective Female Anopheles mosquitoes with sporozoites in the salivary glands anopheline density Number of female anopheline mosquitoes in relation to the number of specified shelters or hosts (e.g. per room, per trap or per person) or to a given period (e.g. overnight or per hour), specifying the method of collection Note: This term refers strictly to the population density or abundance of adult female Anopheles mosquitoes. Anopheline mosquito density is a highly insensitive measure of malaria transmission. anthropophilic Description of mosquitoes that show a preference for feeding on humans, even when non-human hosts are available Note: A relative term requiring quantification to indicate the extent of preference for anthropophily versus zoophily; usually expressed as the human blood index (proportion of mosquitoes that have fed on humans out of total fed) antimalarial medicine A pharmaceutical product used in humans for the prevention, treatment or reduction of transmission of malaria artemisinin-based combination therapy A combination of an artemisinin derivative with a longer-acting antimalarial drug that has a different mode of action basic reproduction number The number of secondary cases that a single infection (index case) would generate in a completely susceptible population (referred to as R0) Note: The “adjusted reproduction number”, Rc , is the reproduction number in the presence of a range of interventions, e.g. insecticide-treated nets, indoor residual spraying and access to treatment. bioassay In applied entomology, experimental testing of the biological effectiveness of a treatment (e.g. infection, insecticide, pathogen, predator, repellent) by deliberately exposing insects to it Note: When bioassays are used for periodic monitoring of the continued efficacy of residual insecticide deposits on sprayed surfaces in houses (as in indoor residual spraying), attention should be paid to the environmental conditions and possible adverse factors (e.g. washing, re-plastering, soot) that affect the deposits on treated surfaces; these factors may reduce the effectiveness of treatment differently from the intrinsic rate of decay of the insecticide. biting rate Average number of mosquito bites received by a host in a unit time, specified according to host and mosquito species (usually measured by human landing collection) Note: Human malariology mainly requires the “human biting rate” of vectors. capture site Site selected for periodic sampling of the mosquito population of a locality for various purposes 8case, confirmed Malaria case (or infection) in which the parasite has been detected in a diagnostic test, i.e. microscopy, a rapid diagnostic test or a molecular diagnostic test Note: On rare occasions, the presence of occult malaria infection in a blood or organ donor is confirmed retrospectively by the demonstration of malaria parasites in the recipient of the blood or organ. case, fever The occurrence of fever (current or recent) in a person Note: Fever is often used as a screening criterion before performing a diagnostic test to detect malaria. case, imported Malaria case or infection in which the infection was acquired outside the area in which it is diagnosed case, index A case of which the epidemiological characteristics trigger additional active case or infection detection. The term “index case” is also used to designate the case identified as the origin of infection of one or a number of introduced cases. case, indigenous A case contracted locally with no evidence of importation and no direct link to transmission from an imported case case, induced A case the origin of which can be traced to a blood transfusion or other form of parenteral inoculation of the parasite but not to transmission by a natural mosquito-borne inoculation Note: in controlled human malaria infections in malaria research, the parasite infection (challenge) may originate from inoculated sporozoites, blood or infected mosquitoes. case, introduced A case contracted locally, with strong epidemiological evidence linking it directly to a known imported case (first-generation local transmission) case, locally acquired A case acquired locally by mosquito-borne transmission Note: Locally acquired cases can be indigenous, introduced, relapsing or recrudescent; the term “autochthonous” is not commonly used. case, malaria Occurrence of malaria infection in a person in whom the presence of malaria parasites in the blood has been confirmed by a diagnostic test Note: A suspected malaria case cannot be considered a malaria case until parasitological confirmation. A malaria case can be classified as imported, indigenous, induced, introduced, relapsing or recrudescent (depending on the origin of infection); and as symptomatic or asymptomatic. In malaria control settings, a “case” is the occurrence of confirmed malaria infection with illness or disease. In settings where malaria is actively being eliminated or has been eliminated, a “case” is the occurrence of any confirmed malaria infection with or without symptoms. For more discussion on “malaria case”, see the section on “The special case of malaria case”, above. case, presumed Case suspected of being malaria that is not confirmed by a diagnostic test Note: The designation “presumed case” is reserved for uncommon situations in which a diagnostic test cannot be performed in a timely manner. W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 9 case, recrudescent Malaria case attributed to the recurrence of asexual parasitemia after antimalarial treatment, due to incomplete clearance of asexual parasitemia of the same genotype(s) that caused the original illness. A recrudescent case must be distinguished from reinfection and relapse, in case of P. vivax and P. ovale. case, relapsing Malaria case attributed to activation of hypnozoites of P. vivax or P. ovale acquired previously Note: The latency of a relapsing case can be > 6–12 months. The occurrence of relapsing cases is not an indication of operational failure, but their existence should lead to evaluation of the possibility of ongoing transmission. case, suspected malaria Illness suspected by a health worker to be due to malaria, generally on the basis of the presence of fever with or without other symptoms case detection One of the activities of surveillance operations, involving a search for malaria cases in a community Note: Case detection is a screening process in which the indicator is either the presence of fever or epidemiological attributes such as high-risk situations or groups. Infection detection requires use of a diagnostic test to identify asymptomatic malaria infections. case detection, active Detection by health workers of malaria cases at community and household levels, sometimes in population groups that are considered at high risk. Active case detection can consist of screening for fever followed by parasitological examination of all febrile patients or as parasitological examination of the target population without prior screening for fever. Note: Active case detection may be undertaken in response to a confirmed case or cluster of cases, in which a population potentially linked to such cases is screened and tested (referred to as “reactive case detection”), or it may be undertaken in high-risk groups, not prompted by detection of cases (referred to as “proactive case detection”). case detection, passive Detection of malaria cases among patients who, on their own initiative, visit health services for diagnosis and treatment, usually for a febrile illness case follow-up Periodic re-examination of patients with malaria (with or without treatment) Note: Follow-up may involve blood examination and treatment if the patient did not respond to previous medicines. Case follow-up is part of surveillance. case investigation Collection of information to allow classification of a malaria case by origin of infection, i.e. imported, indigenous, induced, introduced, relapsing or recrudescent Note: Case investigation may include administration of a standardized questionnaire to a person in whom a malaria infection is diagnosed and screening and testing of people living in the same household or surrounding areas. case management Diagnosis, treatment, clinical care, counselling and follow-up of symptomatic malaria infections case notification Compulsory reporting of all malaria cases by medical units and medical practitioners to either the health department or the malaria control programme, as prescribed by national laws or regulations 10 catchment area A geographical area defined and served by a health programme or institution, such as a hospital or community health centre, which is delineated on the basis of population distribution, natural boundaries and accessibility by transport cerebral malaria Severe P. falciparum malaria with impaired consciousness (Glasgow coma scale < 11, Blantyre coma scale < 3) persisting for > 1 hour after a seizure Note: The initial neurological symptoms are often drowsiness, confusion, failure to eat or drink or convulsions (see WHO definition of severe malaria in the WHO guidelines for malaria). certification of malaria-free status Certification granted by WHO after it has been proved beyond reasonable doubt that local human malaria transmission by Anopheles mosquitoes has been interrupted in an entire country for at least 3 consecutive years and a national surveillance system and a programme for the prevention of reintroduction are in place chemoprevention, seasonal malaria Intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness. The objective is to maintain therapeutic concentrations of an antimalarial drug in the blood throughout the period of greatest risk for malaria. Note: This intervention is recommended only for areas with highly seasonal malaria, where transmission occurs during a few months of the year. chemoprophylaxis Administration of a medicine, at predefined intervals, to prevent either the development of an infection or progression of an infection to manifest disease cluster Aggregation of relatively uncommon events or diseases in space and/or time in numbers that are considered greater than could be expected by chance combination therapy A combination of two or more classes of antimalarial medicine with unrelated mechanisms of action coverage A general term referring to the fraction of the population of a specific area that receives a particular intervention coverage, universal Access to and use of appropriate interventions by the entire population at risk of malaria cure Elimination from an infected person of all malaria parasites that caused the infection Note: When applied to P. vivax and P. ovale malaria, the term is equivalent to radical cure. cure, radical Elimination of both blood-stage and latent liver infection in cases of P. vivax and P. ovale infection, thereby preventing relapses Note: The term is used only for P. vivax and P. ovale infections, to reflect the use of anti-hypnozoite medicines. cure rate Percentage of treated individuals whose infection is cured cyto-adherence Propensity of malaria-infected erythrocytes to adhere to the endothelium of the micro vasculature of the internal organs of the host diagnosis The process of establishing the cause of an illness (for example, a febrile episode), including both clinical assessment and diagnostic testing W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 11 diagnosis, molecular Use of nucleic acid amplification-based tests to detect the presence of malaria parasites diagnosis, parasitological Diagnosis of malaria by detection of malaria parasites or Plasmodium-specific antigens or genes in the blood of an infected individual diapause Condition of suspended animation or temporary arrest in the development of immature and adult mosquitoes dosage regimen (or treatment regimen) Prescribed formulation, route of administration, dose, dosing interval and duration of treatment with a medicine dose Quantity of a medicine to be taken at one time or within a given period Note: The quantities of antimalarial medicines should be expressed as base (when applicable) and fractions of a gram or milligrams. dose, loading One or a series of doses that may be given at the start of therapy with the aim of achieving the target concentration rapidly drug efficacy Capacity of an antimalarial medicine to achieve the therapeutic objective when administered at a recommended dose, which is well tolerated and has minimal toxicity drug resistance The ability of a parasite strain to survive and/or multiply despite the absorption of a medicine given in doses equal to or higher than those usually recommended Note: Drug resistance arises as result of genetic changes (mutations or gene amplification) that confer reduced susceptibility drug safety (See medicine safety) drug, gametocidal A drug that kills male and/or female gametocytes, thus preventing them from infecting a mosquito drug, schizontocidal A drug that kills schizonts, either in the liver or the blood endemic area An area in which there is an ongoing, measurable incidence of malaria infection and mosquito-borne transmission over a succession of years endemicity, level of Degree of malaria transmission in an area Note: Various terms have been used to designate levels of endemicity, but none is fully satisfactory. Parasite rate or spleen rate has been used to define levels of endemicity in children aged 2–9 years, i.e. hypoendemic: 0–10%; mesoendemic: 10–50%, hyperendemic: constantly > 50% and holoendemic: constantly ≥ 75% with a low adult spleen rate Parasite density decreases rapidly between 2 and 5 years of age. endophagy Tendency of mosquitoes to blood-feed indoors Note: Contrasts with exophagy endophily Tendency of mosquitoes to rest indoors Note: Contrasts with exophily; usually quantified as the proportion resting indoors; used in assessing the effect of indoor residual spraying 12 entomological inoculation rate Number of infective bites received per person in a given unit of time, in a human population Note: This rate is the product of the “human biting rate” (the number of bites per person per day by vector mosquitoes) and the sporozoite rate (proportion of vector mosquitoes that are infective). At low levels of transmission, the estimated entomological inoculation rate may not be reliable, and alternative methods should be considered for evaluating transmission risk. epidemic Occurrence of a number of malaria cases highly in excess of that expected in a given place and time Note: Seasonal increases in the incidence of malaria should not be confused with epidemics. epidemiological investigation Study of the environmental, human and entomological factors that determine the incidence or prevalence of infection or disease Note: In malaria elimination, epidemiological investigation is a part of surveillance operations and involves ascertaining the origin and means of transmission of any malaria case discovered. It involves epidemiological surveys, localized mass blood examinations and entomological surveys to ascertain the existence and nature of any malaria foci in surrounding areas, to establish whether transmission is taking place and, if it is, its source and potential to spread. erythrocytic cycle Portion of the life cycle of the malaria parasite from merozoite invasion of red blood cells to schizont rupture. The duration is approximately 24 h in P. knowlesi, 48 h in P. falciparum, P. ovale and P. vivax and 72 h in P. malariae. exophagy Tendency of mosquitoes to feed outdoors Note: Contrasts with endophagy; usually quantified as the proportions biting hosts outdoors versus indoors, conveniently assessed by comparative human landing catches outdoors and indoors or by observation of biting rates on non-human hosts outdoors exophily Tendency of mosquitoes to rest outdoors Note: Contrasts with endophily; usually quantified as proportions resting outdoors and indoors; used in estimating outdoor transmission risks experimental huts For vector investigations, simulated house with entry and exit traps for sampling mosquitoes entering and exiting, blood-feeding indoors (when a host is present) and surviving or dying in each sub-sample, per day or night Note: Experimental huts are used in standard protocols to evaluate indoor treatments (indoor residual spraying and insecticide-treated nets) against endophilic mosquitoes. fixed-dose combination A combination in which two antimalarial medicines are formulated together in the same tablet, capsule, powder, suspension or granule focus, malaria A defined circumscribed area situated in a currently or formerly malarious area that contains the epidemiological and ecological factors necessary for malaria transmission Note: Foci can be classified as active, residual non-active or cleared. gametocyte Sexual stage of malaria parasites that can potentially infect anopheline mosquitoes when ingested during a blood meal W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 13 gametocyte rate Percentage of individuals in a defined population in whom sexual forms of malaria parasites have been detected Note: This term is generally used to refer to P. falciparum. The detection method used should be mentioned when citing a gametocyte rate. The percentage of cases of falciparum malaria with gametocytes is an indicator of the timeliness of diagnosis and treatment of malaria. geographical reconnaissance Censuses and mapping to determine the distribution of the human population and other features relevant for malaria transmission in order to guide interventions Note: Geographical reconnaissance provides the basis for selecting field centres and depots, for designing schedules and itineraries of operations, planning deployment of transport and assessing completion of planned activities. It can also be used to define, as accurately as possible, the geographical limits of malaria-endemic areas and to assess epidemic potential. gonotrophic cycle, mosquito The period of reproductive development in the female mosquito, including host-seeking, blood feeding, digestion of a blood meal, ovarian development, search for a breeding site and oviposition. Note: Temperature and environmental factors affect the duration of the gonotrophic cycle, which takes a few days or weeks, strongly influencing the vectorial capacity. Before the first oviposition the adult female mosquito is nulliparous; after the first oviposition the female is called parous and primiparous, 2-parous, 3-parous etc according to the number of oviposition. Anophelines exhibit gonotrophic harmony (or concordance) when every blood meal results in one batch of eggs from the gonotrophic cycle. Gonotrophic dissociation occurs when blood feeding is not followed by egg development. In some species, nulliparous females may require two or more blood meals for egg development. gonotrophic discordance (dissociation) Female mosquitoes that take more than one blood meal per gonotrophic cycle hibernation Process in which mosquitoes at one or several stages (eggs, larvae, pupae, adults) survive by means of behavioural or physiological changes during cold periods house Any structure other than a tent or mobile shelter in which humans sleep household The ecosystem, including people and animals occupying the same house and the accompanying vectors house-spraying Application of liquid insecticide formulation to specified (mostly interior) surfaces of buildings human landing catch A method for collecting vectors as they land on individuals Note: The purpose is to monitor exposure of the human population to vector populations. It is used for estimating the “human biting rate”, a basic factor for calculating the basic reproduction number and the vectorial capacity in epidemiological studies. hyperparasit aemia A high density of parasites in the blood, which increases the risk that a patient’s condition will deteriorate and become severe malaria Note: See the WHO definition in the WHO guidelines for malaria. 14 hypnozoite Persistent liver stage of P. vivax and P. ovale malaria that remains dormant in host hepatocytes for variable periods, from 3 weeks to 1 year (exceptionally even longer), before activation and development into a pre-erythrocytic schizont, which then causes a blood-stage infection (relapse) importation rate Rate of influx of parasites via infected individuals or infected Anopheles spp. mosquitoes Note “Infected individuals” includes residents infected while visiting endemic areas as well as infected immigrants. This term replaces the term vulnerability. importation risk Probability of influx of infected individuals and/or infective anopheline mosquitoes incidence, malaria Number of newly diagnosed malaria cases during a defined period in a specified population incubation period Period between inoculation of malaria parasites and onset of clinical symptoms Note: The shortest incubation period in mosquito-borne infections ranges from 7 days for P. falciparum to 23 days for P. malariae malaria. The long incubation for P. vivax and P. ovale malaria (from 3 weeks to 1 year and exceptionally many years) is due to activation of hypnozoites. The incubation period may be shorter in blood-induced infections than in sporozoite-induced infections, depending on the size of the inoculum. index, host preference Proportion of blood-fed female Anopheles mosquitoes that fed on the host species and/or individual of interest Note: Blood-fed female Anopheles mosquitoes are sampled at representative resting sites, and the blood meal of each host species or individual is identified. The methods include “precipitin testing” and molecular assays. index, human blood Proportion of mosquito blood meals from humans index, parasite-density Mean parasite density on slides examined and found positive for a sample of the population; calculated as the geometric mean of individual parasite density counts indoor residual spraying Operational procedure and strategy for malaria vector control involving spraying interior surfaces of dwellings with a residual insecticide to kill or repel endophilic mosquitoes indoors Inside any shelter likely to be used by humans or animals, where mosquitoes may feed or rest Note: Where indoor-resting mosquitoes can be targeted for indoor residual spraying infection, chronic Long-term presence of parasitaemia that is not causing acute or obvious illness but could potentially be transmitted infection, mixed Malaria infection with more than one species of Plasmodium infection, reservoir of Any person or animal in which plasmodia live and multiply, such that they can be transmitted to a susceptible host infection, submicroscopic Low-density blood-stage malaria infections that are not detected by conventional microscopy W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 15 infectious Capable of transmitting infection, a term commonly applied to human hosts infective Capable of producing infection, a term commonly applied to parasites (e.g. gametocytes, sporozoites) or to the vector (mosquito) infectivity Ability of sporozoites of a specific strain of Plasmodium to be injected by Anopheles mosquitoes into susceptible humans and develop through the liver stage to infect red blood cells (“infectivity to humans”) and the ability of competent Anopheles mosquitoes to ingest human Plasmodium gametocytes which undergo development until the mosquito has infective sporozoites in its salivary glands (“infectivity to mosquitoes”). insecticide Chemical product (natural or synthetic) that kills insects. Ovicides kill eggs; larvicides (larvacides) kill larvae; pupacides kill pupae; adulticides kill adult mosquitoes. Residual insecticides remain active for an extended period Note: Insecticides used for malaria vector control are approved by the WHO Vector Control Product Prequalification (https://extranet.who.int/ pqweb/vector-control-products). insecticide, cross- resistance Resistance to one insecticide by a mechanism that also confers resistance to another insecticide, even when the insect population has not been selected by exposure to the latter insecticide discriminating dose, or diagnostic dose for resistance Amount of an insecticide (usually expressed as the concentration per standard period of exposure), which, in a sample of mosquitoes containing resistant individuals, distinguishes between susceptible and resistant phenotypes and determines their respective proportions Note: When the genetic factor for resistance is either dominant or recessive, only one discriminating dose operates. When it is semi- dominant, two such doses may operate: a lower discriminating dose that kills susceptible mosquitoes only and an upper diagnostic dose that kills both susceptible mosquitoes and heterozygous (but not homozygous) resistant mosquitoes. insecticide, dose Amount of active ingredient of insecticide applied per unit area of treatment (mg/m2) for indoor residual spraying and treated mosquito nets, or per unit of space (mg/m3) for space spraying and per unit area of application (g/ha or mg/m2) or per volume of water (mg/L) for larvicides insecticide, mixture Insecticide product consisting of two or more active ingredients mixed as one formulation so that, when applied, the mosquito will contact both simultaneously insecticide mosaic Strategy for mitigating resistance, whereby insecticides with different modes of action are applied in different parts of an area under coverage (usually in a grid pattern), so that parts of the mosquito populations are exposed to one insecticide and others to another Note: This is ideally combined with insecticide rotation, whereby the treatments of the mosaic are switched between areas periodically. 16 insecticide resistance Property of mosquitoes to survive exposure to a standard dose of insecticide; may be the result of physiological or behavioural adaptation Note: The emergence of insecticide resistance in a vector population is an evolutionary phenomenon due to either behavioural avoidance (e.g. exophily instead of endophily) or physiological factors whereby the insecticide is metabolized, not potentiated, or absorbed less than by susceptible mosquitoes. insecticide rotation Strategy involving sequential applications of insecticides with different modes of action to delay or mitigate resistance insecticide tolerance Less-than-average susceptibility to insecticide but not inherited as resistance insecticide, contact Insecticide that exerts a toxic action on mosquitoes when they rest on a treated surface; the insecticide is absorbed via the tarsi (feet). insecticide, fumigant Insecticide that acts by releasing vapour from a volatile substance insecticide, residual Insecticide that, when suitably applied onto a surface, maintains its insecticidal activity for a considerable time by either contact or fumigant action integrated vector management Rational decision-making for optimal use of resources for vector control Note: The aim is to improve the efficacy, cost-effectiveness, ecological soundness and sustainability of vector control activities against vector- borne diseases. intermittent preventive treatment in infants A full therapeutic course of sulfadoxine-pyrimethamine delivered to infants in co-administration with DTP2/Penta2, DTP3/Penta3 and measles immunization, regardless of whether the infant is infected with malaria intermittent preventive treatment in pregnancy A full therapeutic course of antimalarial medicine given to pregnant women at routine prenatal visits, regardless of whether the woman is infected with malaria invasive species A non-native species that establishes in a new ecosystem, and causes, or has the potential to cause, harm to the environment, economy, or human health. Note: In malaria, it refers to Anopheles species. larval source management Management of aquatic habitats (water bodies) that are potential habitats for mosquito larvae, in order to prevent completion of development of the immature stages Note: The four types of larval source management are: habitat modification, which is a permanent alteration of the environment, e.g. land reclamation; habitat manipulation, which is a recurrent activity, e.g. flushing of streams; larviciding, which is regular application of biological or chemical insecticides to water bodies; and biological control, which consists of the introduction of natural predators into water bodies. larvicide Substance used to kill mosquito larvae Note: Larvicides are applied in the form of oils (to asphyxiate larvae and pupae), emulsions or small pellets or granules of inert carrier impregnated with insecticide, which is released gradually when they are placed in water. W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 17 latent period For P. vivax and P. ovale infections, the period between the primary infection and subsequent relapses. This stage is asymptomatic; parasites are absent from the bloodstream but present in hepatocytes. long-lasting insecticidal net A factory-treated mosquito net made of material into which insecticide is incorporated or bound around the fibres. The net must retain its effective biological activity for at least 20 WHO standard washes under laboratory conditions and 3 years of recommended use under field conditions. malaria case (See case, malaria) malaria, cerebral (See cerebral malaria) malaria control Reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts. Continued interventions are required to sustain control. malaria elimination Interruption of local transmission (reduction to zero incidence of indigenous cases) of a specified malaria parasite in a defined geographical area as a result of deliberate activities. Continued measures to prevent re-establishment of transmission are required. Note: The certification of malaria elimination in a country will require that local transmission is interrupted for all human malaria parasites. malaria eradication Permanent reduction to zero of the worldwide incidence of infection caused by human malaria parasites as a result of deliberate activities. Interventions are no longer required once eradication has been achieved. malaria infection Presence of Plasmodium parasites in blood or tissues, confirmed by diagnostic testing Note: Diagnostic testing could consist of microscopy, rapid diagnostic testing or nucleic acid-based amplification (e.g. polymerase chain reaction assays to detect parasite DNA or RNA). malaria mortality rate Number of deaths from malaria per unit of population during a defined period malaria pigment (haemozoin) A brown-to-black granular material formed by malaria parasites as a by-product of haemoglobin digestion. Pigment is evident in mature trophozoites and schizonts. It may also be phagocytosed by monocytes, macrophages and polymorphonuclear neutrophils. malaria prevalence (parasite prevalence) Proportion of a specified population with malaria infection at one time malaria receptivity Degree to which an ecosystem in a given area at a given time allows for the transmission of Plasmodium spp. from a human through a vector mosquito to another human. Note: This concept reflects vectorial capacity, susceptibility of the human population to malaria infection, and the strength of the health system, including malaria interventions. Receptivity depends on vector susceptibility to particular species of Plasmodium, and is influenced by ecological and climatic factors. malaria reintroduction Malaria reintroduction is the occurrence of introduced cases (cases of the first-generation local transmission that are epidemiologically linked to a confirmed imported case) in a country or area where the disease had previously been eliminated Note: Malaria reintroduction is different from re-establishment of malaria transmission (see definition). 18 malaria risk stratification Classification of geographical areas or localities according to factors that determine receptivity and vulnerability to malaria transmission malaria stratification Classification of geographical areas or localities according to epidemiological, ecological, social and economic determinants for the purpose of guiding malaria interventions malaria, cross-border Malaria transmission associated with the movement of individuals or mosquitoes across borders malaria-free Describes an area in which there is no continuing local mosquito- borne malaria transmission and the risk for acquiring malaria is limited to infection from introduced cases malariogenic potential Potential level of transmission in a given area arising from the combination of malaria receptivity, importation rate of malaria parasites and infectivity. Note: The concept of malariogenic potential is most relevant for elimination and prevention of re-establishment when indigenous transmission is mostly or entirely eliminated. malariometric survey Survey conducted in a representative sample of selected age groups to estimate the prevalence of malaria and coverage of interventions Note: Current standards for such surveys are malaria indicator surveys and related demographic and health surveys or multiple indicator cluster surveys. malarious area Area in which transmission of malaria is occurring or has occurred during the preceding 3 years mass drug administration Administration of antimalarial treatment to all age groups of a defined population or every person living in a defined geographical area (except those for whom the medicine is contraindicated) at approximately the same time and often at repeated intervals mass screening Population-wide assessment of risk factors for malaria infection to identify subgroups for further intervention, such as diagnostic testing, treatment or preventive services mass screening, testing and treatment Screening of an entire population for risk factors, testing individuals at risk and treating those with a positive test result mass testing and focal drug administration Testing a population and treating groups of individuals or entire households in which one or more infections is detected mass testing and treatment Testing an entire population and treating individuals with a positive test result medicine safety Characteristics of a medicine that reflects its potential to cause harm, including the important identified risks of a drug and important potential risks Note: The medicine safety specification should also address the populations potentially at-risk (where the product is likely to be used), and outstanding safety questions which require further investigation to refine the benefit-risk profile during the post-approval period (Adapted from ICH E2E definition). merozoite Extracellular stage of a parasite released into host plasma when a hepatic or erythrocytic schizont ruptures; the merozoites can then invade red blood cells. W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 19 monotherapy Antimalarial treatment with a single active compound or a synergistic combination of two compounds with related mechanisms of action national focus register Centralized database of all foci of malaria infection in a country, which includes relevant data on physical geography, parasites, hosts and vectors for each focus national malaria case register Centralized database with individual records of all malaria cases registered in a country net, insecticide- treated Mosquito net that repels, disables or kills mosquitoes that come into contact with the insecticide on the netting material. Insecticide treated nets (ITNs) include those that require treatment and retreatment (often referred to as conventional nets) and those are “long-lasting” (see definition of long-lasting insecticidal net). Note: Untreated mosquito nets can also provide substantial protection against mosquito bites, but they have less effect against vectorial capacity and transmission rates. oocyst The stage of malaria parasite that develops from the ookinete; the oocyst grows on the outer wall of the midgut of the female mosquito. oocyst rate Percentage of female Anopheles mosquitoes with oocysts on the midgut ookinete Motile stage of malaria parasite after fertilization of macrogamete and preceding oocyst formation parasitaemia Presence of parasites in the blood Note: If this condition is not accompanied by symptoms of malaria, it is known as asymptomatic parasitaemia parasitaemia, asymptomatic The presence of asexual parasites in the blood without symptoms of illness parasite clearance time Time between first drug administration and the first examination in which no parasites are present in the blood by microscopy Note: The time depends on the sensitivity of the method used to detect the parasite. parasite density Number of asexual parasites per unit volume of blood or per number of red blood cells Note: Any parasite density can lead to clinical illness; however, the likelihood of clinical illness generally increases with increasing parasite density. parasite density, low Presence of Plasmodium parasites in the blood at parasite density below 100 parasites/μl Note: The term should be accompanied by a description of the method of quantification. The terms “asymptomatic, submicroscopic and low density” are different and should not be used inter-changeably. patent period Period during which malaria parasitaemia is detectable Plasmodium Genus of protozoan blood parasites of vertebrates that includes the causal agents of malaria. P. falciparum, P. malariae, P. ovale and P. vivax cause malaria in humans. Human infection with the monkey malaria parasite P. knowlesi and very occasionally with other simian malaria species may occur in tropical forest areas. 20 population at risk Population living in a geographical area where locally acquired malaria cases have occurred in the past 3 years population, target An implementation unit targeted for activities or services (e.g. prevention, treatment) pre-erythrocytic development Development of the malaria parasite from the time it first enters the host and invades liver cells until the hepatic schizont ruptures Note: After sporozoites are inoculated into a human by a female anopheline mosquito, they invade hepatocytes in the host liver and multiply there for a period ranging from 5.5 (P. falciparum) to 25 days (P. malariae), forming exoerythrocytic schizonts. These then rupture, liberating merozoites into the bloodstream, where they subsequently invade red blood cells. In vivax and ovale infections, some sporozoites remain dormant in the liver in the form of hypnozoites for periods of 3 weeks to 12 months and exceptionally several years. pre-patent period Period between inoculation of parasites and the first appearance of parasitaemia prequalification Process to ensure that health products are safe, appropriate and meet stringent quality standards for international procurement Note: Health products are prequalified by an assessment of product dossiers, inspection of manufacturing and testing sites, quality control testing in the case of vaccines and medicines, validation of the performance of diagnostic tests and verification that the products are suitable for use in the destination countries. preventive chemotherapy Use of medicines either alone or in combination to prevent malaria infections and their consequences Note: Preventive chemotherapy includes chemoprophylaxis, intermittent preventive treatment of infants and pregnant women, seasonal malaria chemoprevention and mass drug administration. prophylaxis Any method of protection from or prevention of disease; when applied to chemotherapy, it is commonly termed “chemoprophylaxis”. prophylaxis, causal Complete prevention of erythrocytic infection by destroying the pre- erythrocytic forms of the parasite rapid diagnostic test Immunochromatographic lateral flow device for rapid detection of malaria parasite antigens rapid diagnostic test, combination Malaria rapid diagnostic test that can detect a number of different malaria species rapid diagnostic test positivity rate Proportion of positive results among all rapid diagnostic tests performed reactive focal screening, testing, treating or drug administration Screening, testing, treating or administering drugs to a subset of a population in a given area in response to the detection of an infected person receptivity Receptivity of an ecosystem to transmission of malaria Note: A receptive ecosystem should have e.g. the presence of competent vectors, a suitable climate and a susceptible population. W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 21 recrudescence Recurrence of asexual parasitaemia of the same genotype(s) that caused the original illness, due to incomplete clearance of asexual parasites after antimalarial treatment. Note: Recrudescence is different from reinfection with a parasite of the same or different genotype(s) and relapse in P. vivax and P. ovale infections. recurrence Reappearance of asexual parasitaemia after treatment, due to recrudescence, relapse (in P. vivax and P. ovale infections only) or a new infection reinfection A new infection that follows a primary infection; can be distinguished from recrudescence by the parasite genotype, which is often (but not always) different from that which caused the initial infection reintroduction risk The risk that endemic malaria will be re-established in a specific area, after its elimination Note: The risk is typically determined by factors including climate, altitude, vector populations, human susceptibility, socio-economic status, urban or rural and coverage of interventions. relapse Recurrence of asexual parasitaemia in P. vivax or P. ovale infections arising from hypnozoites Note: Relapse occurs when the blood-stage infection has been eliminated but hypnozoites persist in the liver and mature to form hepatic schizonts. After an interval, generally from 3 weeks to 1 year, the hepatic schizonts rupture and liberate merozoites into the bloodstream. repellent Any substance that causes avoidance in mosquitoes, especially substances that deter them from settling on the skin of the host (topical repellent) or entering an area or room (area repellent, spatial repellent, excito-repellent) resistance (See drug resistance, Insecticide resistance) ring form (ring stage, ring-stage trophozoite) Young, usually ring-shaped malaria trophozoites, before pigment is evident by microscopy schizont Stage of the malaria parasite in host liver cells (hepatic schizont) or red blood cells (erythrocytic schizont) that is undergoing nuclear division by schizogony and, consequently, has more than one nucleus screening Identification of groups at risk that may require further intervention, such as diagnostic testing, treatment or preventive services selection pressure The force of an external agent that confers preferential survival; examples are the pressure of antimalarial medicines on malaria parasites and of insecticides on anopheline mosquitoes Note: The term is applicable to human populations as well. As a result of selection pressure by malaria, certain genetic disorders (e.g. sickle-cell anaemia and glucose 6-phosphate dehydrogenase deficiency) that reduce the risk of severe malaria are more frequent in malaria-endemic areas. sensitivity (of a test) Measured as the proportion of people with malaria infection (true positives) who have a positive result serological assay Procedure used to measure antimalarial antibodies in serum severe anaemia Haemoglobin concentration of < 5 g/100 mL (haematocrit < 15%) 22 severe falciparum malaria Acute falciparum malaria with signs of severe illness and/or evidence of vital organ dysfunction Note: See WHO definition in the WHO guidelines for malaria. single-dose regimen Administration of a medicine as a single dose to achieve a therapeutic objective slide positivity rate Proportion of blood smears found to be positive for Plasmodium among all blood smears examined specificity (of a test) Measured as the proportion of people without malaria infection (true negatives) who have a negative result sporozoite Motile stage of the malaria parasite that is inoculated by a feeding female anopheline mosquito and may cause infection sporozoite rate Percentage of female Anopheles mosquitoes with sporozoites in the salivary glands spray round Spraying of all sprayable structures in an area designated for coverage in an indoor residual spraying programme during a discrete period Note: Depending on the residual activity of the insecticide and also on the dynamics of transmission, one or more spray rounds a year may be required in the same area. sprayable In the context of a malaria vector control programme, a unit (dwelling, house, room, shelter, structure, surface) suitable for spraying or required to be sprayed Note: In house-spraying operations, usually implemented by indoor residual spraying spraying cycle Repetition of spraying operations at regular intervals, often designated in terms of the interval between repetitions, e.g. a 6-month spraying cycle when spraying is repeated after a 6-month interval Note: Not to be confused with “spray round” spraying frequency Number of regular applications of insecticide per house per year, usually by indoor residual spraying spraying interval Time between successive applications of insecticide spraying, focal Spray coverage by indoor residual spraying and/or space spraying of houses or habitats in a limited geographical area spraying, residual Spraying the interior walls and ceilings of dwellings with a residual insecticide to kill or repel endophilic mosquito vectors of malaria surveillance Continuous, systematic collection, analysis and interpretation of disease-specific data and use in planning, implementing and evaluating public health practice Note: Surveillance can be done at different levels of the health care system (e.g. health facilities, the community), with different detection systems (e.g. case-based: active or passive) and sampling strategies (e.g. sentinel sites, surveys). surveillance, entomological The regular, systematic collection, analysis and interpretation of entomological data for risk assessment, planning, implementation, monitoring and evaluation of vector control interventions W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 23 testing, malaria Use of a malaria diagnostic test to determine whether an individual has malaria infection tolerance A response in a human or mosquito host to a given quantum of infection, toxicant or drug that is less than expected transmission intensity The frequency with which people living in an area are bitten by anopheline mosquitoes carrying human malaria sporozoites Note: Transmission intensity is often expressed as the annual entomological inoculation rate, which is the average number of inoculations with malaria parasites estimated to be received by one person in a given period. Because of the difficulty of measuring entomological inoculation rate, parasite prevalence in young children is often used as a proxy for transmission intensity. transmission season Period of the year during which most mosquito-borne transmission of malaria infection occurs transmission, re-establishment of Renewed presence of a measurable incidence of locally acquired malaria infection due to repeated cycles of mosquito-borne infections in an area in which transmission had been interrupted Note: A minimum indication of possible re-establishment of transmission would be the occurrence of three or more indigenous malaria cases of the same species per year in the same focus, for 3 consecutive years. transmission, interruption of Cessation of mosquito-borne transmission of malaria in a geographical area as a result of the application of antimalarial measures transmission, perennial Transmission that occurs throughout the year with no great variation in intensity transmission, residual Persistence of malaria transmission following the implementation in time and space of a widely effective malaria programme Note: The sources of and risks for “residual transmission” may vary by location, time and the existing components of the current “effective malaria programme”. transmission, seasonal Transmission that occurs only during some months of the year and is markedly reduced during other months transmission, stable Epidemiological type of malaria transmission characterized by a steady prevalence pattern, with little variation from one year to another except as the result of rapid scaling up of malaria interventions or exceptional environmental changes that affect transmission Note: In areas with stable transmission, the affected population often has high levels of immunity, and malaria vectors usually have high longevity and human-biting rates. transmission, unstable Epidemiological type of malaria transmission characterized by large variation in incidence patterns from one year to another Note: In areas with unstable transmission, epidemics are common and the population usually has little immunity. 24 trap, mosquito Device designed for capturing mosquitoes with or without attractant components (light, CO2, living baits, suction) Note: Mosquito traps are used to sample the density of mosquitoes or to study the effects of attractants, repellents or control interventions; mosquito trapping may also be intended for their control. This includes: i) individual devices used to attract mosquitoes with appropriate lures (light, CO2, living baits, etc.); ii) window traps placed on points of entry or exit of mosquitoes into houses, without any lure and being as unobtrusive as possible, meant to study factors such as indoor feeding, delayed mortality or repellency effect of the insecticide used for IRS; iii) killing traps to attract mosquitoes by powerful attractants, chemical or physical, to their death. treatment failure Inability to clear malarial parasitaemia or prevent recrudescence after administration of an antimalarial medicine, regardless of whether clinical symptoms are resolved treatment, anti-relapse Antimalarial treatment designed to kill hypnozoites and thereby prevent relapses or late primary infections with P. vivax or P. ovale treatment, directly observed Treatment administered under the direct observation of a health care worker treatment, first-line Treatment recommended in national treatment guidelines as the medicine of choice for treating malaria treatment, second-line Treatment used after failure of first-line treatment or in patients who are allergic to or unable to tolerate the first-line treatment treatment, presumptive Administration of an antimalarial drug or drugs to people with suspected malaria without testing or before the results of blood examinations are available Note: This practice may lead to wrong treatment of the underlying disease and is only acceptable in exceptional circumstances. It should be reported to guide appropriate action and improvement of the situation. treatment, preventive Intermittent administration of a full therapeutic course of an antimalarial either alone or in combination to prevent malarial illness by maintaining therapeutic drug levels in the blood throughout the period of greatest risk. Note: WHO recommended preventive treatment includes intermittent preventive treatment of infants and pregnant women and seasonal malaria chemoprevention. treatment, radical Treatment to achieve complete cure. This applies only to vivax and ovale infections and consists of the use of medicines that destroy both blood and liver stages of the parasite. trophozoite The stage of development of malaria parasites growing within host red blood cells from the ring stage to just before nuclear division. Trophozoites contain malaria pigment that is visible by microscopy. uncomplicated malaria Symptomatic malaria parasitaemia without signs of severity or evidence of vital organ dysfunction Note: See current WHO definition (Guidelines for the treatment of malaria. Third edition). Malaria-associated disease can be defined more specifically by criteria for the degree of fever (e.g. temperature > 37.5 °C) and level of parasitaemia (e.g. > 5000 parasites/µL). W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 25 vector In malaria, adult females of any mosquito species in which Plasmodium undergoes its sexual cycle (whereby the mosquito is the definitive host of the parasite) to the infective sporozoite stage (completion of extrinsic development), ready for transmission when a vertebrate host is bitten Note: Malaria vector species are usually implicated (incriminated) after field collection and dissection indicates that the salivary glands are infected with sporozoites; specific assays can be used to detect and identify circumsporozoite protein, especially where infection rates are low. vector competence For malaria, the ability of the mosquito to support completion of malaria parasite development after zygote formation and oocyst formation, development and release of sporozoites that migrate to salivary glands, allowing transmission of viable sporozoites when the infective female mosquito feeds again Note: Human malarias are transmitted exclusively by competent species of Anopheles mosquitoes; various plasmodia are transmitted by competent species of mosquitoes of the genera Aedes, Anopheles and Culex and other haematophagous Diptera. vector control Measures of any kind against malaria-transmitting mosquitoes, intended to limit their ability to transmit the disease Note: Ideally, malaria vector control results in reduction of malaria transmission rates, by reducing the vectorial capacity, to a point at which transmission is interrupted. vector susceptibility The degree to which a mosquito population is susceptible (i.e. not resistant) to insecticides Note: Not to be confused with “vector competence” vector, principal The species of Anopheles mainly responsible for transmitting malaria in any particular circumstance Note: Principal vectors may overlap seasonally or alternate in importance. vector, secondary or subsidiary Species of Anopheles thought to play a lesser role in transmission than the principal vector; capable of maintaining malaria transmission at a reduced level vectorial capacity Number of new infections that the population of a given vector would induce per case per day at a given place and time, assuming that the human population is and remains fully susceptible to malaria vigilance A function of the public health services for preventing reintroduction of malaria. 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W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 29 Archived terms biting-capture, biting collection, human bait collection Sampling of populations of mosquitoes and other haematophagous insects by capture when they bite on human bait or other hosts Note: Discouraged for ethical reasons, to prevent human exposure to risks of transmission of vector-borne diseases; human landing collection is the recommended alternative. breeding site, breeding place Obsolete term for larval habitat: site at which developmental stages of mosquitoes (eggs, larvae, pupae) are found, including sites that appear to be ecologically suitable for particular species cure, clinical Relief of symptoms of a malaria attack (e.g. by chemotherapeutic action against asexual erythrocytic parasites), without complete elimination of the infection cure, suppressive Complete elimination of the parasite from the body by means of continuous suppressive treatment discharge register List of patients who leave inpatient hospital care. Discharge registers should contain the date of admission, patient’s name, residence, age, sex, diagnosis, length of stay and reason for leaving (discharged, died, transferred, absconded). This information should be abstracted from the patient file by appropriately trained staff. drug failure Absence or insufficiency of drug action after administration of a normally effective dose. It is important to discriminate between such causes of drug failure as deficient absorption, unusual rate of degradation or excretion of the drug and resistance of the parasite. infection interval Period elapsing from the time an individual is infected until he or she becomes infectious to others. In malaria, the infection interval is the period between the inoculation of a human being with sporozoites and the appearance of gametocytes potentially infective to mosquitos. To be distinguished from incubation interval and incubation period. malaria baseline The malaria burden that would be present in a specific area if there were no control activities. Also termed “intrinsic malaria transmission level” malaria, refractory Term used by some authors to describe persistence or slow, gradual reduction in the prevalence of malaria despite total-coverage spraying malaria, responsive Term used by some authors to describe malaria that is rapidly reduced in prevalence by total-coverage spraying soon after the beginning of the attack phase malaria, sporadic Term applied to malaria when autochthonous cases are too few and scattered to have any appreciable effect on the community. Such cases are often due to relapses of a previous infection. For purposes of epidemiological classification by origin of infection, the term “relapsing “ is preferred. 30 mass blood examination Examination of the blood of all members of a unit of population, which may be repeated at certain intervals. Blood specimens are commonly obtained during house-to-house visits. Unlike other case-detection methods, mass blood examinations are used to detect all people harbouring malaria parasites, even those who have no clinical symptoms; they thus supplement routine methods in problem areas and are useful for demonstrating the proportion of asymptomatic carriers present in the community examined. Mass blood examination forms part of case-detection activities and must be distinguished from malariometric surveys, which are carried out on a sampling basis in selected groups. mass primaquine preventive treatment Administration of primaquine anti-relapse therapy to each individual in a defined population or geographical area during the low- transmission season to eliminate long-latency hypnozoites in infected people, with the aim of reducing P. vivax malaria transmission during the next transmission season. Note: For safety reasons, recipients should be tested for glucose 6-phosphate dehydrogenase activity before the intervention. outbreak A case or a greater number of cases of locally transmitted infection than would be expected at a particular time and place Note: The correct term is “epidemic”. outpatient register List of patients seen in consultation at a health facility. A register may include the date of consultation, patient’s age, place of residence and presenting health complaint, tests performed and diagnosis phase, attack In malaria eradication terminology, the phase during which antimalarial measures that can be used on a large scale for interrupting transmission are applied for total coverage of an operational area. This phase is sometimes called the period of total coverage spraying. phase, consolidation In malaria eradication terminology, the phase that follows the attack phase. It is characterized by active, intense, complete surveillance, with the objective of eliminating any remaining infections and proving the eradication of malaria. It ends when the criteria for eradication have been met. phase, maintenance In malaria eradication terminology, period that begins when the criteria for malaria eradication have been met in an operational area and will continue until worldwide eradication has been achieved. During this period, vigilance is exercised by the public health services to prevent the spread of malaria imported from across the borders of the area concerned. phase, preparatory In malaria eradication terminology, the time devoted to preparation for attack operations. It ends when epidemiological and geographical reconnaissance in the operational area is completed, central and peripheral stations and essential services are established, staff are recruited and trained and logistics and reporting systems are organized. population, vulnerable Groups of people who are particularly vulnerable to malaria infection in certain situations or contexts, such as mobile workers. Each country should define the populations that are particularly vulnerable in the epidemiological and social context. population-based blood survey Survey in which a blood smear is taken on one or more occasions from each individual in a given population (irrespective of history of fever) to assess the prevalence of malaria parasitaemia (both symptomatic and asymptomatic) in the population. Such surveys may also provide supportive evidence of the interruption of transmission. W HO M AL AR IA T ER M IN O LO G Y 20 21 u pd at e 31 potential vector Species with vector competence and appreciable vectorial capacity pre-eradication programme Preliminary operation undertaken in a country in which the general administrative and health services are not yet able to undertake a malaria eradication programme pre-eradication survey Operation for the collection of accurate data on the malaria situation, preliminary to drafting a complete plan of operations for a malaria eradication programme. The undertaking of such a survey presupposes the availability of evidence that transmission can be interrupted by the methods commonly used in malaria eradication and the existence of basic operational facilities. The period of the pre-eradication survey ends when the plan of operations has been prepared. prophylaxis, absolute Absolute prevention of infection, implying destruction of inoculated sporozoites before they can fix themselves in the tissues prophylaxis, clinical Prevention of clinical symptoms by early destruction of erythrocytic parasites. It is considered to suppress malaria when it permits the continued existence of exoerythrocytic forms or of some erythrocytic forms that will permit subsequent multiplication of the parasite after discontinuation of the drug. All blood schizontocides are clinical prophylactic drugs or suppressants, as they destroy merozoites entering the bloodstream before they can establish schizogony. This results in prevention of erythrocytic infection, or at least in its reduction to a sub-patent level while the drug is being taken, but overt attacks may occur after it is discontinued. rate, malaria morbidity Number of recorded clinical cases of malaria per unit of population over a certain period. The malaria morbidity rate is too imprecise to be of value in malaria eradication. rate, parasite Percentage of people in a defined age group showing, on a given date, microscopically detectable parasites in peripheral blood. The parasite rate should always be defined in terms of the age group examined. sub-perennial Transmission occurs throughout the year with peaks of markedly greater intensity in some months. surveillance, active A surveillance system in which public health workers seek reports on a regular basis from participants in the surveillance system, rather than waiting passively for the reports to be submitted surveillance, case- based Each case is reported and investigated immediately and included in the weekly reporting system. Note: Surveillance in which all cases included in the regular reporting system are investigated surveillance, community-based Surveillance in which notification starts at community level, usually reported by a community worker. It can be active (looking for cases) or passive (reporting cases). Community-based surveillance may be particularly useful during an epidemic and when syndromic case definitions can be used. surveillance, hospital- based Surveillance in which notification starts with identification by a hospital of a patient with a particular disease or syndrome surveillance, passive Surveillance in which reports are awaited and no attempt is made to seek reports actively from the participants in the system. surveillance, sentinel Collection and use of data from a random or non-random sample of collecting sites as indicator data for the population as a whole, in order to identify cases of a disease early or to obtain indicative data about trends of a disease or health event that is not malaria specific 32 trap hut Structure adapted for trapping mosquitoes attracted by bait (human or animal) placed inside it Note: The purpose of trap huts is to collect a representative portion of incoming mosquitoes and/or to test the effectiveness of an insecticide. They are usually of simple design, often built of the same materials as local habitations, and are provided with trapping devices – usually one or more window traps – so that mosquitos are trapped as they enter or leave. See also “Experimental hut”. treatment, suppressive Treatment to prevent or eliminate clinical symptoms and/or parasitaemia by early destruction of erythrocytic parasites. It does not necessarily prevent or eliminate the infection, and malaria may become overt after drug withdrawal. treatment, targeted Administration of drugs to a group whose eligibility for treatment is defined by age, sex or social characteristics, irrespective of infection status (exclusion criteria may apply) vector efficiency Imprecise way of ranking vector species or populations as relatively more or less important in transmission Note: More difficult to calculate than vectorial capacity vulnerability The frequency of influx of infected individuals or groups and/or infective anopheline mosquitoes Note: Also referred to as “importation risk”. The term can also be applied to the introduction of drug resistance in a specific area.

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