When it comes to shifting the programs' emphasis from control to elimination of the disease, WHO proposes that the first program reorientation be initiated when the rate of positives slides (or rapid tests) falls below 5%.
Some of the countries in the Americas have been reporting very low slide positivity rates in recent years, coupled with incidence rates well below 5 cases per 1,000 population. But these criteria should not be rigid. What is most important for the Region's malaria programs that are reporting such low transmission rates is to determine whether their foci are well defined and whether they have the capacity to follow up each case individually. If the program meets both these criteria, then it would be in position to progress toward disease elimination and start making the changes proposed here-as long as there is sufficient political will and financial support for assuming the responsibilities entailed. In any case, regardless of the name attached to this phase in the transition of control programs, the operational requirements proposed here constitute a road map for consolidating situations in which transmission of the disease has reached low levels.
The present PAHO Guide defines a list of a program's aspects that should be evaluated to assist managers in the reorientation proposed by WHO. The aim is for countries to be able to use this set of elements both as a checklist to evaluate the current status of their programs and as very concrete milestones in devising the strategic plans that will have to be prepared in moving toward the first program reorientation phase.