WHO

The first meeting of the Emergency Committee (EC) convened by the Director-General under the International Health Regulations (2005) (IHR 2005) regarding clusters of microcephaly cases and other neurologic disorders in some areas affected by Zika virus was held by teleconference on 1 February 2016, from 13:10 to 16:55 Central European Time.

The WHO Secretariat briefed the Committee on the clusters of microcephaly and Guillain-Barré Syndrome (GBS) that have been temporally associated with Zika virus transmission in some settings. The Committee was provided with additional data on the current understanding of the history of Zika virus, its spread, clinical presentation and epidemiology.

The following States Parties provided information on a potential association between microcephaly and/or neurological disorders and Zika virus disease: Brazil, France, United States of America, and El Salvador.

The Committee advised that the recent cluster of microcephaly cases and other neurologic disorders reported in Brazil, following a similar cluster in French Polynesia in 2014, constitutes a Public Health Emergency of International Concern (PHEIC).

The Committee provided the following advice to the Director-General for her consideration to address the PHEIC (clusters of microcephaly and neurologic disorders) and their possible association with Zika virus, in accordance with IHR (2005).

Microcephaly and neurologic disorders

• Surveillance for microcephaly and GBS should be standardized and enhanced, particularly in areas of known Zika virus transmission and areas at risk of such transmission.
• Research into the etiology of new clusters of microcephaly and neurologic disorders should be intensified to determine whether there is a causative link to Zika virus and/or other factors or co-factors.

As these clusters have occurred in areas newly infected with Zika virus, and in keeping with good public health practice and the absence of another explanation for these clusters, the Committee highlights the importance of aggressive measures to reduce infection with Zika virus, particularly among pregnant women and women of childbearing age.

As a precautionary measure, the Committee made the following additional recommendations:

Zika virus transmission

• Surveillance for Zika virus infection should be enhanced, with the dissemination of standard case definitions and diagnostics to at-risk areas.
• The development of new diagnostics for Zika virus infection should be prioritized to facilitate surveillance and control measures.
• Risk communications should be enhanced in countries with Zika virus transmission to address population concerns, enhance community engagement, improve reporting, and ensure application of vector control and personal protective measures.
• Vector control measures and appropriate personal protective measures should be aggressively promoted and implemented to reduce the risk of exposure to Zika virus.
• Attention should be given to ensuring women of childbearing age and particularly pregnant women have the necessary information and materials to reduce risk of exposure.
• Pregnant women who have been exposed to Zika virus should be counselled and followed for birth outcomes based on the best available information and national practice and policies.

Longer-term measures

• Appropriate research and development efforts should be intensified for Zika virus vaccines, therapeutics and diagnostics.
• In areas of known Zika virus transmission health services should be prepared for potential increases in neurological syndromes and/or congenital malformations.

Travel measures

• There should be no restrictions on travel or trade with countries, areas and/or territories with Zika virus transmission.
• Travellers to areas with Zika virus transmission should be provided with up to date advice on potential risks and appropriate measures to reduce the possibility of exposure to mosquito bites.
• Standard WHO recommendations regarding disinsection of aircraft and airports should be implemented.

Data sharing

• National authorities should ensure the rapid and timely reporting and sharing of information of public health importance relevant to this PHEIC.
• Clinical, virologic and epidemiologic data related to the increased rates of microcephaly and/or GBS, and Zika virus transmission, should be rapidly shared with WHO to facilitate international understanding of the these events, to guide international support for control efforts, and to prioritize further research and product development.

Based on this advice the Director-General declared a Public Health Emergency of International Concern (PHEIC) on 1 February 2016. The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005). The Director-General thanked the Committee Members and Advisors for their advice.

List of Members of, and Advisers to, the International Health Regulations (2005) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations

1 February 2016

CHAIR

Professor David L. Heymann

Professor of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom of Great Britain and Northern Ireland

MEMBERS

Dr Fernando Althabe

Director, Department of Maternal and Child Health Research, Institute of Clinical and Health Policy Effectiveness, Buenos Aires, Argentina

Dr Kalpana Baruah

Joint Director, National Vector Borne Disease Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India

Dr Silvia Bino

Associate Professor of Infectious Diseases; Head, Control of Infectious Diseases Department, Institute of Public Health, Tirana, Albania

Professor David O. Freedman

Professor of Medicine and Epidemiology, University of Alabama at Birmingham, United States of America

Dr Abraham Hodgson

Director, Research and Development Division, Ghana Health Service, Accra, Ghana

Dr Nyoman Kandun

Program Director, Field Epidemiology Training Program, Ministry of Health, Jakarta, Indonesia

Dr Ghazala Mahmud

Former Dean, Quaid i Azam Post Graduate Medical College, Pakistan Institute of Medical Sciences; Dean, Faculty of Medicine, Quaid i Azam University, Islamabad, Pakistan

Dr K.U. Menon

Senior Consultant, Ministry of Communications and Information, Singapore

Dr Amadou Sall

Director of the WHO Collaborating Centre for Arboviruses and Viral Haemorrhagic Fevers, Institut Pasteur de Dakar, Senegal

Dr Jennifer Staples

Medical Epidemiologist, Arboviral Disease Branch, Division of Vector-borne Diseases, Centers for Disease Control and Prevention, Atlanta, United States of America

Dr Pedro Fernando da Costa Vasconcelos

Head, Department of Arbovirology and Haemorrhagic Fevers; Director, National Reference Laboratory for Arboviruses; Director, National Institute for Viral Haemorrhagic Fevers, Ananindeua, Brazil

ADVISERS

Dr Férechté Encha-Razavi

Associate Professor, University of Paris-Déscartes, and Senior Consultant, Centres Pluridisciplinaires de Diagnostic Prénatal, Necker-Sick Children’s Hospital, Paris, France

Dr Anthony Evans

Aviation Medicine Consultant, International Civil Aviation Organization, Montreal, Canada

Dr Dirk Glaesser

Director, Sustainable Development of Tourism Programme, World Tourism Organization, Madrid, Spain

Professor Duane J. Gubler

Professor and Founding Director, Signature Research Program in Emerging Infectious Diseases, Duke-Nus Graduate Medical School, Singapore

Dr Leonard Mboera

Chief Research Scientist and the Director of Information Technology and Communication, National Institute for Medical Research, Dar es Salaam,Tanzania

Dr James Meegan

National Institute of Allergy and Infectious Diseases, National Institutes of Health, Office of Global Research, Bethesda, United States of America

Dr Maria Mercedes Muñoz

Coordinator, Public Health Surveillance Group, Department of Epidemiology and Demography, Ministry of Health and Welfare, Bogota, Colombia

Dr Rafael Obregón

Chief, Communication for Development Section, United Nations Children’s Fund, New York, United States of America

WHO

WHO Director-General summarizes the outcome of the Emergency Committee on Zika

I convened an Emergency Committee, under the International Health Regulations, to gather advice on the severity of the health threat associated with the continuing spread of Zika virus disease in Latin America and the Caribbean. The Committee met today by teleconference.

In assessing the level of threat, the 18 experts and advisers looked in particular at the strong association, in time and place, between infection with the Zika virus and a rise in detected cases of congenital malformations and neurological complications.

The experts agreed that a causal relationship between Zika infection during pregnancy and microcephaly is strongly suspected, though not yet scientifically proven. All agreed on the urgent need to coordinate international efforts to investigate and understand this relationship better.

The experts also considered patterns of recent spread and the broad geographical distribution of mosquito species that can transmit the virus.

The lack of vaccines and rapid and reliable diagnostic tests, and the absence of population immunity in newly affected countries were cited as further causes for concern.

After a review of the evidence, the Committee advised that the recent cluster of microcephaly cases and other neurological disorders reported in Brazil, following a similar cluster in French Polynesia in 2014, constitutes an “extraordinary event” and a public health threat to other parts of the world.

In their view, a coordinated international response is needed to minimize the threat in affected countries and reduce the risk of further international spread.

Members of the Committee agreed that the situation meets the conditions for a Public Health Emergency of International Concern.

I have accepted this advice.

I am now declaring that the recent cluster of microcephaly cases and other neurological disorders reported in Brazil, following a similar cluster in French Polynesia in 2014, constitutes a Public Health Emergency of International Concern.

A coordinated international response is needed to improve surveillance, the detection of infections, congenital malformations, and neurological complications, to intensify the control of mosquito populations, and to expedite the development of diagnostic tests and vaccines to protect people at risk, especially during pregnancy.

The Committee found no public health justification for restrictions on travel or trade to prevent the spread of Zika virus.

At present, the most important protective measures are the control of mosquito populations and the prevention of mosquito bites in at-risk individuals, especially pregnant women.

Reuters

** ‘……..”We knew this was something else,” says Carlos Brito, a doctor from Recife who told state and federal health authorities in January-February [2014] that they were wrong to classify all the cases as dengue. “But the authorities were slow to believe,” he said…..’

** “….a group of doctors discussing the odd symptoms in text messages – grew frustrated with the authorities’ narrow focus…..”

**  “…It took until early May for the health ministry to recognize that the Zika virus had arrived in Brazil and to alert the…..Pan American Health Organization. ….”

**  “…And it wasn’t until November that a Rio de Janeiro laboratory made a link between the virus and microcephaly….”

**  ‘…”My chief criticism is of WHO in Geneva. After being widely condemned for acting late on Ebola, it is now sitting back with Zika,” said Lawrence O. Gostin, a professor of public health law at Georgetown University…..’

Reuters

White House

“The President met today with leaders of his health and national security teams to discuss the spread of Zika and other mosquito-borne viruses in the Americas as well as steps being taken to protect the American public. The President’s senior health advisors, including Health and Human Services Secretary Sylvia Mathews Burwell, Centers for Disease Control Director Dr. Thomas Frieden, and NIH/NIAID Director Dr. Anthony Fauci, briefed him on the factors that could affect the potential spread of the Zika virus in the United States, as well as recently issued travel advisories and guidance for domestic health care providers who care for pregnant women. The President was briefed on the potential economic and development impacts of the Zika virus spreading in the Western Hemisphere.  The President emphasized the need to accelerate research efforts to make available better diagnostic tests, to develop vaccines and therapeutics, and to ensure that all Americans have information about the Zika virus and steps they can take to better protect themselves from infection.”

WHO

Report

CDC:   Schuler-Faccini L, Ribeiro EM, Feitosa IM, et al. Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015. MMWR Morb Mortal Wkly Rep 2016;65(Early Release):1–4. DOI: http://dx.doi.org/10.15585/mmwr.mm6503e2er.

CDC:  Hennessey M, Fischer M, Staples JE. Zika Virus Spreads to New Areas — Region of the Americas, May 2015–January 2016. MMWR Morb Mortal Wkly Rep 2016;65(Early Release):1–4. DOI: http://dx.doi.org/10.15585/mmwr.mm6503e1er.

Reuters

WHO-1

WHO-2

Zika virus disease: Questions and answers

Where does Zika virus occur?

Zika virus occurs in tropical areas with large mosquito populations, and is known to circulate in Africa, the Americas, Southern Asia and Western Pacific.

Zika virus was discovered in 1947, but for many years only sporadic human cases were detected in Africa and Southern Asia. In 2007, the first documented outbreak of Zika virus disease occurred in the Pacific. Since 2013, cases and outbreaks of the disease have been reported from the Western Pacific, the Americas and Africa. Given the expansion of environments where mosquitoes can live and breed, facilitated by urbanisation and globalisation, there is potential for major urban epidemics of Zika virus disease to occur globally.

How do people catch Zika virus?

People catch Zika virus by being bitten by an infected Aedes mosquito – the same type of mosquito that spreads dengue, chikungunya and yellow fever.

What are the symptoms of Zika virus disease?

Zika virus usually causes mild illness; with symptoms appearing a few days after a person is bitten by an infected mosquito. Most people with Zika virus disease will get a slight fever and rash. Others may also get conjunctivitis, muscle and joint pain, and feel tired. The symptoms usually finish in 2 to 7 days.

What might be the potential complications of Zika virus?

Because no large outbreaks of Zika virus were recorded before 2007, little is currently known about the complications of the disease.

During the first outbreak of Zika from 2013 – 2014 in French Polynesia, which also coincided with an ongoing outbreak of dengue, national health authorities reported an unusual increase in Guillain-Barré syndrome. Retrospective investigations into this effect are ongoing, including the potential role of Zika virus and other possible factors. A similar observation of increased Guillain-Barré syndrome was also made in 2015 in the context of the first Zika virus outbreak in Brazil.

In 2015, local health authorities in Brazil also observed an increase in babies born with microcephaly at the same time of an outbreak of Zika virus. Health authorities and agencies are now investigating the potential connection between microcephaly and Zika virus, in addition to other possible causes. However more investigation and research is needed before we will be able to better understand any possible link.

Should pregnant women be concerned about Zika?

Health authorities are currently investigating a potential link between Zika virus in pregnant women and microcephaly in their babies. Until more is known, women who are pregnant or planning to become pregnant should take extra care to protect themselves from mosquito bites.

If you are pregnant and suspect that you may have Zika virus disease, consult your doctor for close monitoring during your pregnancy.

What is microcephaly?

Microcephaly is a rare condition where a baby has an abnormally small head. This is due to abnormal brain development of the baby in the womb or during infancy. Babies and children with microcephaly often have challenges with their brain development as they grow older.

Microcephaly can be caused by a variety of environmental and genetic factors such as Downs syndrome; exposure to drugs, alcohol or other toxins in the womb; and rubella infection during pregnancy.

How is Zika virus disease treated?

The symptoms of Zika virus disease can be treated with common pain and fever medicines, rest and plenty of water. If symptoms worsen, people should seek medical advice. There is currently no cure or vaccine for the disease itself.

How is Zika virus disease diagnosed?

For most people diagnosed with Zika virus disease, diagnosis is based on their symptoms and recent history (e.g. mosquito bites, or travel to an area where Zika virus is known to be present). A laboratory can confirm the diagnosis by blood tests.

What can I do to protect myself?

The best protection from Zika virus is preventing mosquito bites. Preventing mosquito bites will protect people from Zika virus, as well as other diseases that are transmitted by mosquitoes such as dengue, chikungunya and yellow fever.

This can be done by using insect repellent; wearing clothes (preferably light-coloured) that cover as much of the body as possible; using physical barriers such as screens, closed doors and windows; and sleeping under mosquito nets. It is also important to empty, clean or cover containers that can hold water such as buckets, flower pots or tyres, so that places where mosquitoes can breed are removed.

Should I avoid travelling to areas where Zika virus is occurring?

Travellers should stay informed about Zika virus and other mosquito-borne diseases and consult their local health or travel authorities if they are concerned.

To protect against Zika virus and other mosquito-borne diseases, everyone should avoid being bitten by mosquitoes by taking the measures described above. Women who are pregnant or planning to become pregnant should follow this advice, and may also consult their local health authorities if travelling to an area with an ongoing Zika virus outbreak.

Based on available evidence, WHO is not recommending any travel or trade restrictions related to Zika virus disease. As a precautionary measure, some national governments may make public health and travel recommendations to their own populations, based on their assessments of the available evidence and local risk factors.

What is WHO doing?

To help countries prepare for and respond to Zika, WHO is working with ministries of health to improve laboratory capacity to detect the virus, providing recommendations for clinical care and follow-up of infected patients (in collaboration with national professional associations and experts), and encouraging monitoring and reporting on the virus’s spread and the emergence of complications.

WHO is also coordinating with countries that have reported outbreaks of Zika virus and other partners to investigate the potential relationships between Zika and microcephaly and other issues.

WHO

On 11 January 2016, the National Health and Family Planning Commission (NHFPC) of China notified WHO of 10 additional laboratory-confirmed cases of human infection with avian influenza A (H7N9) virus, including 3 deaths.

The cases were reported in the provinces of Zhejiang (6), Jiangsu (2), Guangdong (1) and Jiangxi (1). The median age of the patients is 52.5 years old (ranging from 29 to 77 years old). The cases are split equally between men and women. One of the patients is a health care worker. All cases reported a history of exposure to live poultry.

Detailed information concerning these cases can be found in a separate document (see related links).

Public health response

The Chinese Government has taken the following surveillance and control measures:

• strengthening outbreak surveillance and situation analysis;
• reinforcing all efforts on medical treatment; and
• conducting risk communication with the public and dissemination of information.

WHO risk assessment

WHO is assessing the epidemiological situation and conducting further risk assessment based on the latest information. Based on the information received thus far, the overall public health risk from avian influenza A(H7N9) viruses has not changed.

If the pattern of human cases follows the trends seen in previous years, the number of human cases may rise over the coming months. Further sporadic cases of human infection with avian influenza A(H7N9) virus are expected in affected and possibly in the neighboring areas. Should human cases from affected areas travel internationally, their infection may be detected in another country during travels or after arrival. If this were to occur, community level spread is considered unlikely as the virus has not demonstrated the ability to transmit easily among humans.

WHO advice

WHO advises that travellers to countries with known outbreaks of avian influenza should avoid poultry farms, contact with animals in live bird markets, entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with faeces from poultry or other animals. Travellers should also wash their hands often with soap and water. Travellers should follow good food safety and good food hygiene practices.

WHO does not advise special screening at points of entry with regard to this event, nor does it currently recommend any travel or trade restrictions. As always, a diagnosis of infection with an avian influenza virus should be considered in individuals who develop severe acute respiratory symptoms while travelling or soon after returning from an area where avian influenza is a concern.

WHO encourages countries to continue strengthening influenza surveillance, including surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns, in order to ensure reporting of human infections under the IHR (2005), and continue national health preparedness actions.

WHO

**  This date marks the first time since the start of the epidemic 2 years ago that all 3 of the hardest-hit countries—Guinea, Liberia and Sierra Leone—have reported 0 cases for at least 42 days.

**  More flare-ups are expected

**  Strong surveillance and response systems will be critical in the months to come.

WHO

New report signals country progress in the path to malaria elimination

9 DECEMBER 2015 ¦ Brussels – New estimates from WHO show a significant increase in the number of countries moving towards malaria elimination, with prevention efforts saving millions of dollars in healthcare costs over the past 14 years in many African countries.

According to the “World Malaria Report 2015”, released today, more than half (57) of the 106 countries with malaria in 2000 had achieved reductions in new malaria cases of at least 75% by 2015. In that same time frame, 18 countries reduced their malaria cases by 50-75%.

Across sub-Saharan Africa, the prevention of new cases of malaria has resulted in major cost savings for endemic countries. New estimates presented in the WHO report show that reductions in malaria cases attributable to malaria control activities saved an estimated US$ 900 million in case management costs in the region between 2001 and 2014. Insecticide-treated mosquito nets contributed the largest savings, followed by artemisinin-based combination therapies and indoor residual spraying.

“Since the start of this century, investments in malaria prevention and treatment have averted over 6 million deaths,” said Dr Margaret Chan, WHO Director-General. “We know what works. The challenge now is to do even more.”

Regional progress

For the first time since WHO began keeping score, the European Region is reporting zero indigenous cases of malaria. This achievement was made possible through strong country-level leadership, technical support from WHO and financial assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Since 2000, the malaria mortality rate has declined by 85% in the South-East Asia Region, by 72% in the Region of the Americas, by 65% in the Western Pacific Region, and by 64% in the Eastern Mediterranean Region. While the African Region continues to carry the highest malaria burden, here too there have been impressive gains: over the last 15 years, malaria mortality rates fell by 66% among all age groups, and by 71% among children under five, a population particularly susceptible to the disease.

Progress towards global targets

Country-level and regional progress in malaria control is reflected in global disease trends. Since 2000, malaria incidence and death rates have fallen by 37% and 60%, respectively, around the world. Among children under five, malaria death rates have declined by 65%. An estimated 6.2 million deaths have been averted since 2000.

According to the report, Target 6C of the Millennium Development Goals—which aimed to halt and reverse the global incidence of malaria between 2000 and 2015—has been achieved. Substantial progress has also been made towards the 2005 World Health Assembly target of a 75% reduction in the global burden of malaria by 2015.

Scale-up in malaria control

Progress has resulted, in large part, from the massive deployment of effective and low-cost malaria control interventions. Since 2000, nearly 1 billion insecticide-treated mosquito nets have been distributed in sub-Saharan Africa. By 2015, about 55% of the population in this region was sleeping under mosquito nets, up from less than 2% coverage in 2000.

Rapid diagnostic tests have made it easier to swiftly distinguish between malarial and non-malarial fevers, enabling timely and appropriate treatment. A sharp increase in diagnostic testing for malaria has been reported in the WHO African Region: from 36% of suspected malaria cases in 2005 to 65% of cases in 2014. Artemisinin-based combination therapies (ACTs), introduced widely over the past decade, have been highly effective against P. falciparum, the most prevalent and lethal malaria parasite affecting humans.

An estimated 663 million cases of malaria have been averted in sub-Saharan Africa since 2001 as a direct result of the scale-up of three key malaria control interventions: insecticide-treated mosquito nets, indoor residual spraying and artemisinin-based combination therapy. Mosquito nets have had the greatest impact, accounting for about 68% of cases prevented through these interventions.

Still a long road

Despite progress, significant challenges remain. Globally, about 3.2 billion people—nearly half of the world’s population—are at risk of malaria. In 2015, there were estimated 214 million new cases of malaria, and approximately 438 000 deaths.

Fifteen countries, mainly in Africa, account for most global malaria cases (80%) and deaths (78%). According to the report, these high burden countries have achieved slower-than-average declines in malaria incidence (32%) compared to other countries globally (53%). In many of these countries, weak health systems continue to impede progress in malaria control.

Millions of people are still not receiving the services they need to prevent and treat malaria. In 2014, approximately one third of people at risk of malaria in sub-Saharan Africa lived in households that lacked protection from mosquito nets or indoor residual spraying.

Insecticide and drug resistance

“As the global burden of malaria declines, new challenges have emerged,” says Dr Pedro Alonso, Director of the WHO Global Malaria Programme. “In many countries, progress is threatened by the rapid development and spread of mosquito resistance to insecticides. Drug resistance could also jeopardize recent gains in malaria control.”

Since 2010, 60 of the 78 countries that monitor insecticide resistance have reported mosquito resistance to at least one insecticide used in nets and indoor spraying; of these, 49 reported resistance to two or more insecticide classes. Parasite resistance to artemisinin— the core compound of the best available antimalarial medicines—has been detected in 5 countries of the Greater Mekong subregion.

Closing gaps

In May 2015, the World Health Assembly adopted the WHO “Global Technical Strategy for Malaria 2016-2030”, a new 15-year framework for malaria control in all endemic countries. The strategy sets ambitious but achievable targets for 2030, including a reduction in global malaria incidence and mortality of at least 90%; the elimination of malaria in at least 35 countries; and the prevention of a resurgence of malaria in all countries that are malaria free.

Achieving these targets will require country leadership, sustained political commitment and a tripling of global investment for malaria control: from the US $2.7 billion in annual funding available today to US $8.7 billion in annual funding by 2030. This figure takes into account future savings in case management costs anticipated as malaria control efforts continue to expand and more cases are averted.

Other key findings from the report

• Globally, the number of malaria cases fell from an estimated 262 million in 2000 (range 205–316 million) to 214 million in 2015 (range 149–303 million).
• Globally, the number of malaria deaths fell from an estimated 839 000 in 2000 (range 653 000 to 1.1 million), to 438 000 in 2015 (range 236 000–635 000).
• Among children under five, the estimated number of malaria deaths, globally, fell from 723 000 in 2000 (range 563 000–948 000) to 306 000 in 2015 (range 219 000–421 000). The bulk of this decrease occurred in the WHO African Region.
• Most malaria cases (88%) and deaths (90%) occurred in the WHO African Region in 2015.
• Two countries, Nigeria and Democratic Republic of Congo, accounted for more than 35% of global malaria deaths in 2015.
• The WHO South-East Asia Region accounted for 10% of global malaria cases and 7% of deaths in 2015.
• The WHO Eastern Mediterranean Region accounted for 2% of global malaria cases and 2% of deaths in 2015.
• In 2014, 16 countries reported zero indigenous cases of malaria: Argentina, Armenia, Azerbaijan, Costa Rica, Iraq, Georgia, Kyrgyzstan, Morocco, Oman, Paraguay, Sri Lanka, Tajikistan, Turkey, Turkmenistan, United Arab Emirates and Uzbekistan. Seventeen countries are reporting fewer than 1000 cases of malaria.

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