Freedom from Infection: Confirming Interruption of Malaria Transmission

The global reductions in disease burden and the continued spread of drug and insecticide resistance make malaria elimination both viable and imperative, although this may be more easily achieved in some settings compared to others. Whilst the focus has been on optimal approaches to achieve elimination, less attention has been paid to how to measure the absence of malaria. Measuring the absence of transmission poses a specific challenge in that it involves proving a negative. The concept of freedom from infection, routinely used in veterinary epidemiology, can provide quantitative and reproducible estimates that, if infections were present above a predefined (low) threshold, they would be detected with a known uncertainty. Additionally, these methods are adaptable for both passively and actively collected data as well as combining information when multiple surveillance streams are available. Here we discuss the potential application of this approach to malaria.