**7. Technological innovation for malaria elimination**

The technical challenges discussed here suggest that the currently used malaria control tools (RDT, ACT, LLIN, and IRS) that were instrumental for the gains against malaria may not be sufficient for malaria elimination [144]. Additional tools are needed to achieve the final goal of malaria elimination in the GMS. First, residual transmission requires MDA to eliminate asymptomatic and submicroscopic parasite reservoirs. For the success of MDA, better knowledge of malaria epidemiology is needed so that targeted MDA can be implemented. Successful MDA programs also require strong community engagement. MDA has proved successful in eliminating malaria in Asia-Pacific regions such as Vanuatu and central China [145, 146]. In an earlier study conducted in Cambodian villages, MDA of artemisinin-PPQ at 10-day intervals for 6 months drastically reduced *P. falciparum* rates [147]. A recent pilot MDA study conducted in villages of Kayin State, Myanmar, showed that a 3-day supervised course of DHA/PPQ was well tolerated and highly effective in reducing asymptomatic *P. falciparum* carriage, whereas the effect on reducing *P. vivax* was transient presumably due to relapse [148]. Thus, drugs targeting the *P. vivax* hypnozoite reservoir are required for MDA in the GMS, where *P. vivax* is becoming the predominant parasite species [149]. The high prevalence of G6PD deficiency in the target populations demands prescreening using a point-of-care diagnostic for G6PD deficiency. From a programmatic standpoint, such an operation requires substantial financial commitment. Second, effective management of malaria cases in the face of emergence and spread of drug resistance requires new therapies such as triple ACTs. Third, novel vector control approaches are desperately needed including larval control strategies [150], incorporation of ivermectin in the MDA program to reduce the life span of mosquitoes [151, 152], topical and spatial repellents against outdoor biting vectors [153, 154], genetically manipulated mosquitoes for population replacement [155], and next generation of LLINs and IRS [156]. It is imperative that new interventions are continuously developed and integrated into malaria elimination programs.

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