Challenges to Achieving Malaria Elimination in Nigeria

Aribodor D. N., Ugwuanyi I. K., Aribodor O. B.

American Journal of Public Health Research

Challenges to Achieving Malaria Elimination in Nigeria

Aribodor D. N.1,, Ugwuanyi I. K.1, Aribodor O. B.2

1Department of Parasitology and Entomology, Faculty of Biosciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria

2Department of Zoology, Faculty of Biosciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria

Abstract

Malaria remains the most important public health parasitic disease and a major global health problem with the greatest burden in sub-Saharan Africa. Over 90% of all malaria deaths still occur in Africa where it kills over half a million children less than 5 years of age each year. Nigeria accounts for 25 percent of the world’s malaria burden. Apart from the health burden, the socio-economic consequences of malaria are enormous such that it was part of the Millennium Development Goals (MDGs). Following the end of MDG target to halt and reverse the incidence of malaria by 2015 which was considered a success, a new global target has been set. The new global strategy aims to reduce the global disease burden of malaria by 40% by 2020, and by at least 90% by 2030. It also aims to eliminate malaria in at least 35 new countries by 2030. Nigeria remains endemic for malaria and has the ambition to eliminate malaria. There are however challenges to confront in order to make the desired progress. Drug resistance, treatment failure, insecticide resistance, global warming and change in climate, conflicts, insurgency, and internally displaced persons, migration, lack of political will, inadequate malaria leadership, funding, and adequate local research constitute the challenges. Addressing these challenges is central to achieving malaria elimination.

Cite this article:

  • Aribodor D. N., Ugwuanyi I. K., Aribodor O. B.. Challenges to Achieving Malaria Elimination in Nigeria. American Journal of Public Health Research. Vol. 4, No. 1, 2016, pp 38-41. http://pubs.sciepub.com/ajphr/4/1/6
  • N., Aribodor D., Ugwuanyi I. K., and Aribodor O. B.. "Challenges to Achieving Malaria Elimination in Nigeria." American Journal of Public Health Research 4.1 (2016): 38-41.
  • N., A. D. , K., U. I. , & B., A. O. (2016). Challenges to Achieving Malaria Elimination in Nigeria. American Journal of Public Health Research, 4(1), 38-41.
  • N., Aribodor D., Ugwuanyi I. K., and Aribodor O. B.. "Challenges to Achieving Malaria Elimination in Nigeria." American Journal of Public Health Research 4, no. 1 (2016): 38-41.

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1. Introduction

Malaria remains the world most important parasitic disease of public health importance. The Roll Back Malaria (RBM) Initiative was launched in 1998 with the aim to markedly reduce malaria morbidity and mortality. In the year 2000, the world launched Millennium Development Goals (MDGs) and Goal 6C was to halt and reverse the incidence of malaria by 2015 [1]. Following the end of MDG, the World Health Organization member states, Nigeria inclusive, on 20th May, 2015 agreed a new global malaria strategy for 2016-2030 [2]. The strategy aims to reduce the global disease burden by 40% by 2020, and by at least 90% by 2030. It also aims to eliminate malaria in at least 35 new countries by 2030.

Between 2000 and 2013, the global malaria mortality rate dropped by 47% [3]. A major expansion of the WHO-recommended core package of measures – vector control, chemoprevention, diagnostic testing and treatment – proved both cost effective and efficient. Nevertheless, millions of people are still unable to access malaria prevention and treatment, and most cases and deaths continue to go unregistered and unreported. In 2013, malaria killed an estimated 584 000 people with over 2 million cases [3]. Nigeria is reported to have the unenviable record of contributing about 25% of the world malaria burden [4]. Nigeria also has the ambition to achieve malaria elimination and has rebranded the National Malaria Control Programme (NMCP) to National Malaria Elimination Programme (NMEP). But beyond the change in nomenclature are important issues and challenges that need to be confronted in order to achieve malaria elimination. These are discussed and addressing these challenges is central to achieving malaria elimination in Nigeria.

2. Notable Challenges in Achieving Malaria Elimination in Nigeria

1. Drug Resistance and Treatment Failure

Malaria drugs are meant to clear malaria parasites from the blood of an infected person and in the process diminish sources of infection in the community. Drug resistance defined as the ability of a parasite strain to survive and or multiply despite the administration and absorption of drug given in doses equal to or higher than those usually recommended but within the tolerance of the subject [5], is a major challenge in the fight against malaria. Chloroquine used to be the drug of choice against malaria but chloroquine resistance that swept across endemic countries in the 1980s was the reason for treatment policy change that gave rise to the use of Artemisinin-based combination therapy (ACT) as the current drug of choice. ACT has played a major part in reducing the number of deaths due to malaria over the past decade [6]. However, Artemisinin-resistant Plasmodium falciparum has recently spread across large parts of southeast Asia, and now threatens to destabilise malaria control worldwide [5-10][5]. With suspected cases of treatment failures which drug resistance could be a factor, it is doubtful if Nigeria has research-based data on the status of ACT, vis-à-vis resistance to P. falciparum and any role in treatment failures, hence a challenge to overcome.

Related to drug resistance is treatment failure. A failure to clear malaria parasites or resolve clinical disease following drug treatment could be a function of non- patency and not necessarily drug resistance as not all cases of treatment failure is a function of drug resistance. Many factors can contribute to malaria treatment failure including incorrect dosing, non-compliance with the duration of dosing regimen, poor drug quality, drug interaction, and improper or misdiagnosis. The role of each of these in malaria treatment failures in Nigeria is not known and need to be studied in the effort to eliminate the disease.

2. Insecticide resistance

Anopheles mosquitoes are vectors of malaria parasites. Control of Anopheline vectors of malaria relies on the use of Long-Lasting Insecticide Nets (LLINs) and Indoor Residual Spraying (IRS). The benefits of the use of these methods have been noted in many countries [11]. However, this success is being impeded by the development and spread of insecticide resistance malaria vectors in Africa, which may compromise the use of these vector control strategies. Only 4 classes of insecticide (carbamates, organophosphates, organochlorines and pyrethroids) are available for IRS, whereas the use of LLINs depends exclusively on pyrethroids. In Nigeria, Anopheline vector resistance to DDT and pyrethroids have been reported [12-17][12]. The emergence of pyrethroid and DDT resistance in the major Afro-tropical malaria vectors would have considerable implications for the success of vector intervention and the monitoring of ongoing control programmes. Hence, there is a strong need for the development of appropriate tools to monitor resistance in field populations of Anopheline mosquitoes in order to benefit from the contributions of the appropriate use of chemical insecticides in malaria elimination in Nigeria.

3. Global Warming and Climate Change

Available data suggest that the temperature of the world is increasing, with the last decade recorded as having the highest temperature [18, 19, 20, 21]. This increase in global temperature mainly as a result of human activities, including burning of fossil fuel and deforestation, is known as global warming. Global warming changes the climate, and climatic factors play important roles in the spatial and temporal distribution of malaria [22, 23]. The relationship between climatic variables and malaria transmission has been reported in many countries [21-25][21]. Malaria has been identified as one of the most climate sensitive diseases [26],with studies suggesting significant associations between temperature and malaria incidence [27]. Relative humidity [26, 27] and rainfall [19, 28] have also been associated with malaria transmission. The spatial limits of the distribution and seasonal activity are sensitive to climatic factors, as well as the local capacity to control the disease. Climate change expressed through changes in temperature and precipitation influences habitat suitability and can potentially shift the geographical range of malaria. Warmer temperatures accelerate physiological processes of the mosquito vector, leading to increased activity such as biting rate, growth, development and reproduction. Extreme temperatures may also decrease survivorship of vectors, leading to a convex relationship between temperature and mosquito performance [29]. In particular, temperature plays a key limiting role on malaria at the edge of the altitudinal distribution of the disease in highland regions, where the parasite is not likely to complete development during the lifetime of its vector [29]. Climate change and drug resistance have been typically addressed as independent drivers of malaria trends, and have been considered as alternative explanations for the exacerbation of the disease in East African highlands [30, 31]. Drivers of malaria control and elimination need information to guide vector control challenges in an era of climate changes. Therefore, there is work to be done in this regard.

4. Conflicts, terrorism, insurgency, internally displaced persons and migration

Civil wars have many negative consequences which include the destruction of civil infrastructures and the loss of human lives. There are many other important consequences related with the health status of the surviving victims of the civil war which can have very long lasting effects on the productivity of the economy and the health conditions of the country. The infection with the malaria parasite is one of these circumstances. The massive movement of non-immune people across areas infested with the malaria vector is one of the consequences of civil wars. A typical example is the decades of war in Sudan which destroyed physical infrastructure, social structures and virtually collapsed the health system [32]. The malaria control situation is threatened by the impact of refugees, returnees, internally displaced populations, and natural disasters, i.e. flooding, that put added strain on an already weakened system from years of conflict and that may destabilize whatever gains that have been made. The situation is aggravated by an increase in population due to refugees, returnees and internally displaced persons. Accordingly, the country experiences exceedingly high malaria transmission intensities with inherent high morbidity and mortality rates [33].

Nigeria today is plagued by conflicts, terrorism, insurgency, migration and internally displaced persons. Virtually all regions of the country are affected with the northeast bearing the highest burden. Every effort is needed to understand the dynamics of this issue in the effort to control and eliminate malaria.

5. Attitude and Behaviour Change

Perceptions about malaria illness, particularly households’ perceived susceptibility and beliefs about the seriousness of the disease, are important preceding factors for decision-making concerning preventive and curative actions [34]. The understanding of the possible causes, modes of transmission, and individual preference and decision-making about the adoption of preventive and control measures vary from community to community and among individual households [35]. Misconceptions concerning malaria still exist [36] and practices for the control of malaria have been unsatisfactory [36, 37, 38, 39]. Attitudes and practices about malaria and the effective use of intervention tools by households and individuals contribute immensely to sustainable control of the disease.

It is important in Nigeria to understand the culture and traditions of malaria endemic communities, as these form the basis of community members’ values, which shape community members’ attitudes on topics like malaria control and elimination. Often these local beliefs influence community members’ action or inactions more than any other factor in the fight against the disease.

6. Political will, leadership and funding

An important action for mobilizing and encouraging governments to continue to support malaria programmes is to generate political will. Since 2000, there has been an increasing political drive to eliminate malaria [40]. The transition from sustained control, once achieved, to elimination demands a shift in focus. It requires significant national commitment, and sustained investment and financial support [41]. To maintain a malaria-free status, a country must show that it has the necessary political will and vision, has created the required legislative and regulatory framework and has adequate financial and administrative resources, personnel and technological capacity [42]. Effective and sustained control is an important prerequisite for elimination. An ongoing poll on the most important factor to progress to malaria global eradication, produced political will as the most critical factor with 74% of respondents voting for the option. Other responses were vaccine (20%), get new and effective public health insecticides (4%), get the next generation of drugs (3%) [42]. Hence the most important challenge in battle against malaria in Nigeria is the lack of political will. Until this is overcome, achieving elimination may be a mirage.

When there is the desired political will, effective leadership will emerge to coordinate elimination efforts. Nigeria needs to take up leadership roles in all aspects of malaria control and elimination, galvanize support and direction operations. Political leaders should muster the political will to create an enabling environment within which strategies to support elimination would operate: appropriate research, a well functioning health system, community participation, sustainable financing, a national and regional legal framework, and political stability are all crucial [43]. Politicians and policy makers need to understand that malaria elimination is a duty Nigeria should perform. It is important that the community should take responsibility for their own health and that community leaders should be involved in malaria prevention campaigns [44].

A certain level of financial support is required to achieve elimination, prevent resurgence and support larger goals of regional elimination and global eradication. Funding for malaria prevention in Africa over the past decade has had a substantial impact on reducing the burden of malaria [45]. These successes have been made possible by a marked increase in international and domestic funding for malaria control. Unfortunately, the donor funding has spawned dependency and expectation among its recipients. Interventions that are externally funded are not sustainable [41]. Should it disappear, or radically diminish, donor-dependent countries would be hard-pressed to finance malaria control efforts and the consequences will be severe. Internal funding, therefore, should always represent the ultimate goal of local malaria interventions to ensure that such interventions are sustainable in the long term.

7. Research

Local governments, states, regional and country-wide research studies in various aspects of malaria are desired for malaria elimination in Nigeria. Local produce or novel intervention tools are imperatives for malaria elimination. The malaria elimination surveillance research and development agenda needs to develop tools and strategies for active and prompt detection of infection. The capacity to assess trends and respond without delay will need to be developed, so that surveillance itself becomes an intervention. Research is needed to develop sensitive field tests that can detect low levels of parasitaemia and/or evidence of recent infection [46]. Residual and outdoor transmission, falling out of reach of currently available prevention measures, particularly for mobile people, constitute another emerging challenge for which new tools and strategies are urgently needed [47, 48].

3. Conclusion

Malaria elimination in Nigeria is a realistic possibility. Sustained efforts are critical to addressing the identified challenges. Local effort is the key and individual person the target. Surveillance systems must be refined and regularly updated for targeted interventions and to ensure the information required to inform an elimination agenda are routinely collected. Stakeholders should therefore act with a shared and focused goal; to create a Nigeria where no one dies of malaria.

Acknowledgements

We would like to acknowledge the many local and non-local persons who have devoted their effort and time in combating malaria as a public health challenge in Nigeria.

Competing Interests

The authors declare that they have no competing interests.

References

[1]  United Nations (2014). The Millennium Development Goals report 2014. United Nations, New York. Available: http://www.un.org/millenniumgoals/2014%20MDG%20report/MDG%202014%20English%20web.pdf. [Accessed December 12, 2015].
In article      
 
[2]  WHO (201/5). Global technical strategy for malaria (2016-2030). World Health Organization. 20 Avenue Appia, 1211 Geneva 27, Switzerland.
In article      
 
[3]  World Health Organization (2014). World malaria report 2014. Available: http://www.who.int/malaria/publications/world_malaria_report_2014/report/en/. [Accessed 23 November, 2015].
In article      
 
[4]  World Health Organization (2012) Roll Back Malaria Partnership, WHO Focus in Nigeria. Progress and Impact Series. Community Report. 4: 58.
In article      
 
[5]  World Health Organisation (2015). Antimalarial Drug Resistance. Available: http://www.who.int/malaria/areas/drug_resistance/overview/en/. [Accessed July 11, 2015].
In article      
 
[6]  World Health Organization (2014). Update on artemisinin resistance ‐ September 2014. Geneva, World Health Organization.
In article      
 
[7]  Kyaw, M.P., Nyunt, M.H., Chit, K., Aye, M.M. and Aye, K.H. (2013). Reduced susceptibility of Plasmodium falciparum to artesunate in southern Myanmar. PLoS ONE 8(3): e57689.
In article      
 
[8]  Phyo, A.P., Nkhoma, S., Stepniewska, K., Ashley, E.A. and Nair, S. (2012). Emergence of artemisinin‐ resistant malaria on the western border of Thailand: a longitudinal study. Lancet 379(9830): 1960-1966.
In article      
 
[9]  Hien, T.T., Thuy‐Nhien, N.T., Phu, N.H., Boni, M.F. and Thanh, N.V. (2012). In vivo susceptibility of Plasmodium falciparum to artesunate in Binh Phuoc Province, Vietnam. Malaria Journal 11: 355.
In article      
 
[10]  Ariey, F., Witkowski, B., Amaratunga, C., Beghain, J. and Langlois, A.C. (2014). A molecular marker of artemisinin‐resistant Plasmodium falciparum malaria. Nature 505(7481): 50-55.
In article      
 
[11]  Hemingway, J. and Ranson, H. (2000) Insecticide resistance in insect vectors of human disease. Annual Review of Entomology, 45, 371-391.
In article      
 
[12]  Awolola, T.S., Brooke, B.D., Hunt, R.H. and Coetzee, M. (2002). Resistance of the malaria vector Anopheles gambiae s.s. to pyrethroid insecticides in southwestern Nigeria. Ann Trop Med Parasitol., 96: 849-52.
In article      
 
[13]  Awolola, T.S., Brooke, B.D., Koekemoer, L.L. and Coetzee, M. (2003). Absence of the kdr mutation in the molecular 'M' form suggests different pyrethroid resistance mechanisms in the malaria vector mosquito Anopheles gambiae s.s. Trop. Med. Int. Health., 8 (5): 420-422.
In article      
 
[14]  Awolola, T.S., Oyewole, I.O., Amajoh, C.N., Idowu, E.T., Ajayi, M.B., Oduola, A., Manafa, O.U., Ibrahim, K., Koekemoer, L.L., Coetzee, M. (2005). Distribution of the molecular M and S forms of Anopheles gambiae and pyrethroid knockdown resistance gene in Nigeria. Acta Tropica, 95: 204-209.
In article      
 
[15]  Awolola, T.S., Oduola, A.O., Oyewole, I.O., Obansa, J.B., Amajoh, C.N., Koekemoer, L.L. and Coetzee, M. (2007). Dynamics of knockdown pyrethroid insecticide resistance alleles in a field population of Anopheles gambiae in Southwestern Nigeria. J. Vect. Borne. Dis., 44: 181-188.
In article      
 
[16]  Awolola, T.S., Oduola, O.A., Strode, C. and Koekemoer, L.L. (2008). Evidence of multiple pyrethroid resistance mechanisms in the malaria vector Anopheles gambiae sensu stricto from Nigeria. Trans. R. Soc. Trop. Med. Hyg., 103 (11): 1139-45.
In article      
 
[17]  Okorie, P.N., Ademowo, O.G., Irving, H., Kelly-Hope, L.A. and Wondji, C.S. (2015). Insecticide susceptibility of Anopheles coluzzi and Anopheles gambiae in Ibadan, Southwest Nigeria. Medical and Veterinary Entomology 29: 44–50.
In article      
 
[18]  Ezenduka, C.C., Ogbonna, B.O., Ekwunife, O.I., Okonta, M.J. and Esimone, C.O. (2014). Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy. Malaria Journal 13:243
In article      
 
[19]  Craig, M., Snow, R. and Le Sueur, D. (1999). A climate-based distribution model of malaria transmission in sub-Saharan Africa. Parasitol Today; 6(3):105-110.
In article      
 
[20]  Tanser, F., Sharp, B. and Le Sueur, D. (2003). Potential effect of climate change on malaria transmission in Africa. Lancet, 6(9398):1792-1798
In article      
 
[21]  Craig, M., Kleinschmidt, I., Nawn, J., Le Sueur, D. and Sharp, B. (2004). Exploring 30 years of malaria case data in KwaZulu‒Natal, South Africa: part I. The impact of climatic factors. Trop Med Int Health, 6(12):1247-1257.
In article      
 
[22]  Hay, S.I., Cox, J., Rogers, D.J., Randolph, S.E., Stern, D.I., Shanks, G.D., Myers, M.F. and Snow, R.W.. (2002). Climate change and the resurgence of malaria in the East African highlands. Nature, 6(6874):905-909.
In article      
 
[23]  Paaijmans, K.P., Read, A.F. and Thomas, M.B. (2009). Understanding the link between malaria risk and climate. Proc Natl Acad Sci USA, 6(33): 13844-13849.
In article      
 
[24]  Kim, Y.M., Park, J.W. and Cheong, H.K. (2012). Estimated effect of climatic variables on the transmission of plasmodium vivax malaria in the Republic of Korea. Environ Health Perspect, 6(9): 1315.
In article      
 
[25]  Gagnon, A.S., Smoyer-Tomic, K.E. and Bush, A.B. (2002). The El Nino southern oscillation and malaria epidemics in South America. Int J. Biomet, 6(2):81-89.
In article      
 
[26]  Githeko, A.K., Lindsay, S.W., Confalonieri, U.E. and Patz, J.A. (2000). Climate change and vector-borne diseases: a regional analysis. Bull of the World Health Organization ,6(9):1136-1147.
In article      
 
[27]  Li, T., Yang, Z. and Wang, M. (2013). Temperature, relative humidity and sunshine may be the effective predictors for occurrence of malaria in Guangzhou, southern China, 2006–2012. Parasites and Vectors, 6(1):155.
In article      
 
[28]  Zucker, J.R. (1996). Changing patterns of autochthonous malaria transmission in the United States: a review of recent outbreaks. Emerg Infect Dis.;6(1):37.
In article      
 
[29]  Artzy-Randrup, Y., Alonso, .D. and Pascual, M. (2010). Transmission Intensity and Drug Resistance in Malaria Population Dynamics: Implications for Climate Change. PLoS ONE 5(10): e13588.
In article      
 
[30]  Hay, S., Cox, J., Rogers, D., Randolph, S. and Stern, D. (2002) Climate change and the resurgence of malaria in the East African highlands. Nature 415: 905-909.
In article      
 
[31]  Shanks, G., Hay, S., Omumbo, J. and Snow, R. (2005) Malaria in Kenya’s Western Highlands. Emerging Infectious Diseases 11(9).
In article      
 
[32]  Pasquale, H., Jarvese, M., Julla, A., Doggale, C., Sebit, B., Lual, M., Baba, S.P. and Chanda E. (2013). Malaria control in South Sudan, 2006-2013: Strategies, progress and challenges. Malaria Journal, 12:374.
In article      
 
[33]  Ross (2009). Malaria indicator survey report, Republic of south Sudan. Juba: Ministry of Health.
In article      
 
[34]  Rakhshani, F., Ansari, M.A., Alemi, R. and Moradi, A. (2003). Knowledge, perceptions and prevention of malaria among women in Sistan va Baluchestan, Islamic Republic of Iran. Eastern Mediterranean Health Journal 9:248-256.
In article      
 
[35]  Adongo, P.B., Kirkwood, B. and Kendall, C. (2005). How local community knowledge about malaria affects insecticide-treated net use in northern Ghana. Tropical Medicine and International Health 10:366-378.
In article      
 
[36]  Aribodor, D.N., Udeh, A.K., Ekwunife, C.A., Aribodor, O.B. and Emelummadu, O.F. (2014). Malaria Prevalence and Local Beliefs in Transmission and Control in Ndiowu Community, Anambra State, Nigeria. Nigerian Journal of Parasitology 35 (1and 2): 103-108.
In article      
 
[37]  Alaii, J.A., Van den Borne, H., Kachur, S.P., Shelley, K., Mwenesi, H., Vulule, J.M., Hawley, W.A., Nahlen, B.L. and Phillips-Howard, P.A. (2003). Community reactions to the introduction of permethrin-treated bed nets for malaria control during a randomized controlled trial in Western Kenya. The American Journal of Tropical Medicine and Hygiene 68:128-136.
In article      
 
[38]  Laver, S.M., Wetzels, J. and Behrens, R.H. (2001). Knowledge of malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travelers exiting Zimbabwe from Harare and Victoria Falls International airport. Journal of Travel Medicine 8:298-303.
In article      
 
[39]  Obol, J., David Lagoro, K. and Christopher Garimoi, O. (2011). Knowledge and Misconceptions about Malaria among Pregnant Women in a Post-Conflict Internally Displaced Persons’ Camps in Gulu District, Northern Uganda. Malaria Research and Treatment 2011:1-7.
In article      
 
[40]  Roll Back Malaria (2011). Eliminating malaria: learning from the past, looking ahead, Progress and Impact Series, Volume 8. Geneva: World Health Organization.
In article      
 
[41]  Whittaker, M., Dean, A.J. and Chancellor, A. (2014). Advocating for malaria elimination - learning from the successes of other infectious disease elimination programmes. Malaria Journal 13:221.
In article      
 
[42]  Ejov, M., Davidyants, V. and Zvantsov, A. (2014). To maintain its malaria-free status, a country must show that it has the necessary political will and vision, has created the required legislative and regulatory framework and has adequate financial and administrative resources, personnel and technological capacity. WHO regional office for Europe .Pp 16.
In article      
 
[43]  Moonen, B., Cohen, J.M. and Snow, R.W. (2010). Operational strategies to achieve and maintain malaria elimination. Lancet; published online Oct 29.
In article      
 
[44]  Mlozi, M.R.S., Shayo, E.H., Senkoro, E.H. and Mayala, B.K. (2006). Participatory involvement of farming communities and public sectors in determining malaria control strategies in Mvomero District, Tanzania. Tanzaian. Health Research Bulletin, 8:134-140
In article      
 
[45]  O’Meara, W.P., Bejon, P., Mwangi, T.W. and Okiro, E.A. (2008). Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya. Lancet, 372:1555-1562.
In article      
 
[46]  Bennett, S., Singh, S., Ozawa, S. and Tran, N.. (2011). Sustainability of donor programs: evaluating and informing the transition of a large HIV prevention program in India to local ownership. Global Health Action 4:7360.
In article      
 
[47]  Slutsker, L. (2012). Challenges in surveillance and response. Malaria Journal, 11(Suppl 1).
In article      
 
[48]  New challenges for malaria control and elimination: the role of operational research for innovation in designing interventions. Availlable: http://www.initiative5pour100.fr/wp-content/uploads/2014/12/Workshop-Malaria-BKK-5PC-Initiative_Programme.pdf. Accessed July 19, 2015.
In article      
 
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