To conduct an in-depth investigation of the epidemiology of malaria in the Papua New Guinea (PNG) highlands and provide a basis for evidence-based planning and monitoring of intensified malaria control activities.

Between December 2000 and July 2005, 153 household-based, rapid malaria population surveys were conducted in 112 villages throughout the central PNG highlands. The presence of malaria infections was determined by light microscopy and risk factors assessed using a structured questionnaire.The combined dataset from all individually published surveys was reanalysed.

The prevalence of malaria infections in the different surveys ranged from 0.0% to 41.8%(median 4.3%) in non-epidemic surveys and 6.6% to 63.2% (median 21.2%, P < 0.001) during epidemics. Plasmodium falciparum was the predominant infection below 1400 m and during epidemics, Plasmodium vivax at altitudes >1600 m. Outside epidemics, prevalence decreased significantly with altitude, was reduced in people using bed nets [odds ratio (OR) = 0.8, P < 0.001] but increased in those sleeping in garden houses (OR = 1.34, P < 0.001) and travelling to highly endemic lowlands (OR = 1.80, P < 0.001). Below 1400 m, malaria was a significant source of febrile illness. At higher altitudes, malaria was only a significant source of febrile illness during epidemic outbreaks, but asymptomatic malaria infections were common in non-epidemic times.

Malaria is once again endemic throughout the PNG highlands in areas below 1400–1500 m of altitude with a significant risk of seasonal malaria outbreaks in most area between 1400–1650 m. Ongoing control efforts are likely to result in a substantial reduction in malaria transmission and may even result in local elimination of malaria in higher lying areas.