As national malaria control programs contemplate their options for shifting tactics and tools to support malaria elimination,1 it is useful to compare and contrast how decreased transmission shifts the diagnostic focus:

• While control phase priorities aim to reduce the morbidity and mortality from malaria, elimination prioritizes driving human infection to zero. Thus, passive infection detection strategies that dominate a control program focus need to be augmented by active infection detection tactics in an elimination context.
• In an elimination context, parasite reservoirs are often characterized by lower density, sub-patent infections. Thus, tests capable of accurate detection at levels below that of traditional microscopy and rapid diagnostic tests (RDTs) are desired.
• Changes in malaria epidemiology that are associated with low transmission often result in clustered populations of both symptomatic and asymptomatic individuals that represent a transmission risk. To achieve the most efficient diagnostic and treatment coverage with active detection tactics targeting these groups, portable, point-of-care tests that provide rapid results without loss to follow-up are needed.
• Successful control programs targeting Plasmodium falciparum (P. falciparum; Pf) often result in a proportional increase in Plasmodium vivax (P. vivax; Pv), Plasmodium malariae (P. malariae; Pm), and Plasmodium knowlesi (P. knowlesi; Pk) and non-malaria febrile illness incidence – thus, differential diagnoses of individual malaria species from other febrile illness gain importance in the elimination context.
• The costs and risks associated with investigating and treating false positives in low prevalence, elimination settings increase the emphasis on diagnostic specificity.
• Decreased budgets and the cost of maintaining strong surveillance systems and national surveys emphasize the importance of cost-efficient diagnostic systems in elimination context.
• The risk of malaria strains developing resistance to drugs and detection emphasizes the importance of detect-and-treat programs with high levels of temporal efficiency. Thus, high coverage levels and high diagnostic sensitivities are paramount to expedient elimination.