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

## TL;DR

This paper describes how Suriname managed a Plasmodium vivax outbreak using a six-pronged strategy, combining traditional and innovative methods to control malaria in a region close to elimination.

## Contribution

The paper introduces an adaptive, integrated six-pronged approach for managing P. vivax outbreaks in low-endemic or near-elimination regions.

## Key findings

- The outbreak lasted 22 months with 179 infections, highlighting the challenges of P. vivax relapses.
- Mass drug administration was more effective than mass screen-and-treat in reducing parasite prevalence.
- The 'Radical Cure' treatment was key in ending the outbreak and preventing relapses.

## Abstract

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.

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.

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.

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.

In 2004, Suriname still had the highest concentration of Plasmodium falciparum malaria cases in the Americas. Thanks to intensive control and surveillance efforts, the country reported zero indigenous cases since 2021. However, imported cases from neighboring high-endemic countries continue to pose a risk for reintroduction of malaria, as seen in the recent P. vivax outbreak in the Amerindian village of Pelele Tepoe. Our findings of the outbreak response demonstrate the success of a flexible, integrated six-pronged strategy, tailored to local needs and evolving conditions. A detailed description is provided of the implementation and effectiveness of each approach including the “1-3-7” surveillance, vector control and culturally sensitive community engagement. We also explain the rationale for implementing additional, less conventional targeted strategies with key measures as mass drug administration, molecular outbreak reconstruction, and new re-treatment protocols aimed at curtailing P. vivax relapses. Factors that contributed to the outbreak’s lengthy duration are discussed, including the COVID-19 pandemic impact and we share lessons learned, particularly the role of relapses and the importance of “Radical Cure” treatment. These insights offer valuable guidance for low-endemic countries or regions nearing malaria elimination, those facing reintroduction risks and regions struggling with persistent P. vivax relapses.