A six-pronged approach to manage a Plasmodium vivax outbreak in a low- and middle-income country on the road to malaria elimination

Abstract

Background Malaria remains a global health concern, with Plasmodium vivax as predominant species in the Americas. The region has made notable strides in reducing malaria incidence, but challenges persist. Guiana Shield countries share similar malaria ecologies and vector dynamics, yet their progress toward elimination is quite different. Suriname, a low-middle income country, has pursued malaria elimination and became the first Amazonian country to receive malaria-free certification in June 2025. However, the reintroduction through imported cases from neighboring countries with higher endemicity remains a serious threat, as exemplified by the 2019 outbreak in Pelele Tepoe. The response strategy and operational measures implemented to address this P. vivax outbreak are described, along with key lessons for effective outbreak management. Methods This descriptive study examines Suriname's most recent P. vivax outbreak, using surveillance and intervention data from November 2019 to August 2021. It outlines the rationale for employing an adaptive, multi-pronged outbreak management strategy, details implementation of approaches, tailored to evolving outbreak circumstances and evaluates the effectiveness of subsequent interventions. Factors contributing to the outbreak's prolonged duration, including COVID-19 pandemic impact are discussed, along with the resulting adaptations in the targeted responses. Results The P. vivax outbreak lasted 22 months, resulting in 179 infections among 153 patients. Traditional strategies with corresponding interventions were introduced at onset, including “1-3-7” surveillance, community education and engagement and vector control. Continuous trend monitoring guided the adoption of additional less conventional and innovative measures, including mass screen-and-treat, mass drug administration (MDA), parasite genotyping and targeted treatment. Mass screen-and-treat was less effective in reducing parasite prevalence than MDA. Directly observed treatment reached 95.1% efficacy by day 180, however, relapses appeared to fuel the outbreak. Implementation of the “Radical Cure” marked the end of the outbreak. Conclusions The described adaptive, integrated, six-pronged approach, combining conventional strategies with targeted accelerator methods and inclusive stakeholder engagement can effectively control outbreaks in low-endemic or near-elimination regions.