**8. Socio-ecological and adaptive management of malaria ecosystem in areas approaching malaria elimination**

WHO has recently proposed sustainable prevention and control of diseases emerging within complex, dynamic, adaptive systems, such as malaria, based on interdisciplinary and approaches addressing environmental and social health determinants holistically [161]. More insights into transmission dynamics and the possibility of intersectoral ecosystem management programs for malaria elimination and control are urgently needed. An ecosystem approach to successful reduction of vector-borne disease burden [162, 163] can lead to considerable health gains [Available at: http://www.maweb.org/documents/document.317.aspx.pdf].

address this problem in Southeast Asia before it can become a threat in Africa. Continuous monitoring of drug resistance in conjunction with analysis and proper interpretation is critical to guide the appropriate action for effective treatment. While *P. falciparum* elimination in the GMS is realistic, feasible and particularly urgent in the context of drug resistance, the main challenges are to ensure community participation and plan for the preservation of ACT potency so that the dosing regimens and surveillance for resistance are rigorously pursued to

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We support a priority focus on MMP and other high-risk groups to contain the spread of artemisinin resistance and new hot-spots, however, implementation challenges should be considered when planning future interventions. More efforts are needed in documenting the malaria risk among different types of MMPs, innovative tools and interventions, as well as designing implementation in a way that can be evaluated, lessons learned, and programmes adapted in an on-going process [172]. New ways of evaluating MMP interventions (including highly sensitive RDTs) are needed, as routine health information systems have limitations and might not allow capturing the information and data needed, and existing type of surveys

Malaria programmes need to heed the recent revised WHO recommendations for achieving universal coverage with LLINs or IRS for populations at risk [173]. The coverage of key interventions is critically low in some countries and sub-optimal in most others, threatening progress across the region as a whole [174]. Malaria programmes are encouraged to evaluate the magnitude (and drivers) of the residual transmission in their country, regarding both mosquito and human behavior. This information will provide a boost for industry and academic partners to develop new vector control methods and paradigms for outdoor and residual transmission. The current precarious funding situation could undermine elimination efforts and result in a resurgence of disease. The threat posed to regional and global malaria control and elimination efforts by artemisinin resistant *P. falciparum* parasites is imminent and potentially severe. In many Asian countries, operational feasibility of *P. vivax* elimination is lower than that for *P. falciparum* [27]. Therefore, creating a viable strategy to achieve vivax elimination goals should include improvements in access to safe treatment to 8-aminoquinoline drugs based radical cure together

Whilst human *P. knowlesi* is still largely a zoonosis, all indications suggest that human-to human transmission can take place, and probably is taking place in some situations [175]. More research is required to substantiate the body of evidence for human-to-human transmission, laboratory diagnosis and clinical management, and mapping vectors of *P. knowlesi* and

The challenge for elimination programmes is dealing with dynamic, social-ecological systems for which an entirely different kind of thinking and scientific framework is required. The retooling for this next phase is more challenging this time since it requires malaria experts and managers to understand complex systems, thinking and practices. This thinking and actions are more or less contrary to conventional understandings of disease control, which tend to be top down and not guided by concepts like resilience and adaptive management developed as

sustain their efficacy for as long as possible [172].

might not be sufficient for monitoring interventions for MMP.

with improved access to adequate G6PD testing in *P. vivax* endemic countries.

environmental risk factors.

part of so-called ecosystem approach/management.

Once local entomological inoculation rates (EIRs) have been reduced to a level of unstable transmission the infectious reservoir can be eliminated via several approaches without a threat of malaria re-emergence from reintroduction of parasites. At this point, use of time-limited mass drug administrations (MDA) campaign at high coverage should be sufficient to effectively clear the majority of remaining *P. falciparum* cases, and may be considered for epidemic control as part of the initial response, along with the urgent introduction of other interventions [164]. This can be supplemented by screening and treatment programmes based on WHO Global Malaria Programme's T3: Test, Treat, Track initiative supporting malaria-endemic countries in their efforts to achieve universal coverage with diagnostic testing and antimalarial treatment, as well as in strengthening their malaria surveillance system [WHO T3: Test, Treat, Track. Scaling up diagnostic testing, treatment and surveillance for malaria. World Health Organisation; 2012. http://www.who.int/malaria/publications/atoz/t3\_brochure/en/]. Healthcare workers or locally trained and supervised community volunteer networks can apply this method to effectively limit reintroduction of parasites from other areas to a minimum, and apply additional active case management, e.g., the systematic detection and treatment of parasitemia using highly sensitive RDTs can reduce the risk attributed to any unscreened or asymptomatic cases.

Depending on the local situations, supplementary measures, in addition to LLINs or IRS, such as repellents or treated clothing for high-risk individuals, offer special precautionary preventive protection [1, 110, 165, 166]. Passive case management should suffice for treating any symptomatic infections as they may occur. This, however, assumes at least a periodic provision of health services at all locations, including remote ones. A transdisciplinary approach integrates different scientific perspectives [167, 168] and provides a formal platform for stakeholder participation in the research and development of new information, ideas and strategies, their testing and eventual application.

Participatory approaches that engage local communities in a complex social-ecological mapping process are a vital starting point for identifying community-applicable solutions and leveraging community capacity for local interventions [169, 170] and promoting integrative and equitable collaboration within partnership of researchers and communities [170, 171]. Ownership of continuous surveillance, monitoring, treatment and preventive efforts should be transferred to members of local communities, assuming collective responsibility for their continuous well-being.
