Note that the information on this website may not be sufficient to guide appropriate approaches since these can be highly specific to the local context so professional advice should be sought.

Greater Mekong Sub-region (GMS)

In the GMS malaria is transmitted mostly by An. dirus and An. minimus which are extremely efficient malaria vectors primarily found in forested and forest fringe areas. Although habits vary both geographically and seasonally, they primarily bite outdoors in the first two quarters of the night. The rate of outdoor early evening biting has increased following the widespread use of LLINs. Despite the reduced level of protection of LLINs, they are still highly recommended although they should be complemented with other measures to combat outdoor transmission. Understanding local vector behaviour is important in the design of an appropriate approach.

Transmission can be intense but is usually highly focal and often sporadic; the high-risk groups include all those spending nights in forest or forest fringe areas. These include forest-based communities (often ethnic minority groups), forest workers (such as soldiers, forest/wildlife protection workers, timber extraction teams, gem miners, wood cutters and hunters), forest fringe agricultural workers (especially seasonal migrants) and rubber tappers).

Recommended options for the GMS setting are:

1. Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are peak biting times and whether vectors primarily bite and rest indoors or outdoors.
2. If entomological surveys show any level of indoor biting or resting then indoor residual spraying may be appropriate for shelters in which people sleep, eat, work or spend their recreational time. Click here for more information on IRS.
3. Use indoor residual spraying on the walls and roofs of any semi-outdoor areas such as verandas, covered recreational areas etc. Click here for more information on IRS.
4. Fit all doors and windows with mosquito screens. Click here for more information on screening.
5. Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs.
Consider site location: the further away that sites can be located from forest fringe, the lower the transmission risk is likely to be. On large sites it would be beneficial to locate sleeping areas, evening recreational areas or areas where night time work is carried out as far away from forest cover as possible.
6. Personal protection measures should include:
   1. Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country
   2. Application of repellents in the early evening hours, especially by workers who are typically outside throughout the night (e.g. security guards, night shift workers and those working in or near forested areas). Click here for more information on repellents.
   3. Consider these other personal protection measures for personnel who spend most of their working hours outdoors during and between dusk and dawn:
      • Insecticide treated clothing/ uniforms
      • Insecticide treated scarfs or other traditional clothing for those used to wearing these
7. Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click access guidance on setting up locally appropriate treatment approaches.
8. Health promotion and communications activities are key to promoting safe prevention and treatment seeking behaviours. Click here for more information on communications components of a control strategy.

APMEN has developed country profiles and other summary resources on malaria control with more detailed information specific to countries within the region. You can access these here.

Pacific Sub-region

The epidemiology of malaria in the Pacific sub-region is highly complex due in part to the diversity of behaviours exhibited by the different sibling species that make up the An. farauti and An. punctulatus species complexes. Breeding site selection, which is often determined by tolerance to salinity, and adult feeding behaviour varies throughout the region. These behaviours have a major effect on transmission patterns; in some settings for example, transmission takes place mostly in coastal areas. However, some generalizations can be drawn. In most areas a significant proportion of transmission occurs indoors late at night, which means that the use of insecticide treated nets should have a strong protective effect. Some indoor resting occurs in most areas and so IRS is also generally useful.

Larval control may be feasible in defined areas where all breeding sites can be mapped and accessed. However, generally this approach is not feasible as most vectors breed in a range of small, scattered temporary pools. Measures should be taken to avoid the creation of new breeding sites (during construction work for example) since An. punctulatus can rapidly increase in numbers in response to a proliferation of breeding sites.

In some countries, such as the Solomon Islands, wide-spread use of insecticide based control measures has reduced the importance of An. punctulatus as a vector, but has also resulted in a shift in the biting behaviour of An. farauti, which now bites earlier and outdoors. This means that ITNs and IRS alone are insufficient to provide full protection against malaria.

Recommended options for the Pacific setting include:

1. Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are the distribution and type of larval breeding sites as well as biting behaviour (time and location).
2. Indoor residual spraying on the walls and ceilings of houses and any semi-outdoor areas such as verandas, covered recreational areas etc. in which people spend time at night sleeping, eating, working or relaxing. Click here for more information on IRS.
3. Fit all doors and windows with mosquito screens. Click here for more information on screening.
4. Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs.
5. Personal protection measures should include:
   Compelling reasons to veer from national guidelines when considering employee
   1. Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country. Where malaria transmission is highly seasonal, seasonal chemoprophylaxis could be considered.
   2. Application of repellents in the early evening hours and later at night for those who are exposed to vector biting, especially by workers who are typically outside throughout the night (e.g. security guards and night shift workers). Click here for more information on repellents.
6. Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click click here to access guidance on setting up locally appropriate treatment approaches.
7. Health promotion and communications activities are key to promoting prevention and safe treatment seeking behaviours. Click here for more information on the communications component of a control strategy.

Special case: Indonesia Indonesia has a particularly complex malaria profile and here generalizations are more difficult to make than elsewhere.

Indonesia spans the Asia and Pacific sub-regions and has a large number of malaria transmission profiles. Bali, Java and Batam have low transmission. Sumatra, Kalimantan and Sulawesi have moderate transmission. All other provinces have moderate to high transmission.

There is high diversity of vector species on the major islands. For example, in Sumatra, An. sinensis is found inland along with the An. barbirostris complex, An. leucosphyrus/An. latens and the An. minimus complex. A number of other vector species also exist on Sumatra but none are considered dominant on the island; hence they are over- laid by the other, more dominant species. Alongside the An. sundaicus complex distributed along the coast, An. flavirostris does increase in relative ‘dominance’, by virtue of a reduced presence of other species, extending southward through Java until it is the only dominant vector species found in the Lesser Sunda islands. In Sumatra, there is very little overlap amongst the dominant species found, suggesting that each occupies a separate niche. Anopheles balabacensis dominates across most of Borneo, with some impact by the An. barbirostris complex and An. leucosphyrus/latens inland and the An. sundaicus complex on the coast. This APMEN profile gives more detail about the complex Indonesian setting.

South Asia Sub-region

Here transmission is dominated by An. culicifacies, An. stephensi and to a lesser extent An. fluviatilis. An. stephensi is the only urban vector. These vectors are common across a range of habitats and transmission is often fairly wide-spread rather than focal. The urban vectors are especially adapted to these contexts and can breed in numerous man-made containers and structures.

In cooler parts of South Asia such as Afghanistan and northern Pakistan, malaria is at the fringe of its range and transmission is fairly unstable and very seasonal, with little to no transmission in the cooler winter months.

These vectors can bite both indoors and outdoors and biting is usually during the late evening and night. They often rest indoors; in rural areas most frequently in livestock sheds. The indoor resting means that indoor residual spraying can be highly effective in these areas. Insecticide treated nets are also useful and where people sleep outside during the hotter months outdoor use of nets has been successfully promoted. Depending on the result of entomological surveys and on the context, larval control through environmental management or larviciding can sometimes be useful.

Recommended options for the South Asia setting are:

1. Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are: the distribution and type of larval breeding sites, level of preference for human hosts and night biting behaviour (time and location).
2. Indoor residual spraying of walls and ceilings in dwellings, livestock sheds and shelters. Click here for more information on IRS.
3. Fit all doors and windows with mosquito screens. Click here for more information on screening.
4. Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs.
5. Based on the result of the entomological surveys, larval control measures may be appropriate in some settings, particularly urban settings or areas which are predominantly dry with few breeding sites.
6. Personal protection measures should include:
   1. Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country
   2. Where malaria transmission is highly seasonal, seasonal chemoprophylaxis could be considered.
   3. Application of repellents in the early evening hours and later at night for those who are exposed to vector biting, especially by workers who are typically outside throughout the night (e.g. security guards and night shift workers). Click here for more information on repellents.
7. Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click click here to access guidance on setting up locally appropriate treatment approaches.
8. Health promotion and communications activities are key to promoting prevention and safe treatment seeking behaviours. Click here for more information on the communications component of a control strategy.

Examples of successful industry malaria control programmes
Sources of technical support and advice

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