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Anopheles mosquito. Credit: James Gathany

Study demonstrates mass drug administration effective at supporting malaria elimination in remote ‘hotspots’ of Myanmar

24 June 2018

A study recently published in The Lancet suggests that early diagnosis and treatment combined with mass drug administration significantly decreased P. falciparum incidence in certain malaria hotspot areas of Eastern Myanmar

The spread of artemisinin resistant P. falciparum malaria and subsequent loss of partner antimalarial drugs in the Greater Mekong Sub-region (GMS) threatens the global control and elimination of malaria – and could put millions of lives at risk. Remote regions like Eastern Myanmar present further challenges scarce health clinics, ineffective use of antimalarial drugs and inconsistent vector control.

The study lead by Prof François Nosten, Director of the Shoklo Malaria Research Unit (SMRU) in Mae Sot, Thailand highlights that, “There has been no clear containment strategy in the region so, despite substantial international investment in regional malaria control, drug-resistant malaria now extends across the whole of the Greater Mekong sub-region (GMS). This study provides hard evidence that it is possible to eliminate artemisinin-resistant falciparum malaria rapidly if the will and the financial support are forthcoming,”

The study identified key elements to successful malaria elimination. Between May 2014 and April 2017, the research team opened 1,222 malarial health posts in four townships. Villagers were trained and supported to work in the communities to detect, treat and monitor malaria for the nearly 365,000 people living in an 18,000 km2 area of eastern Myanmar’s Karen/Kayin State. By April, 2017, 965 villages (79%) of 1,222 corresponding to 104 village tracts were free from P falciparum malaria for at least 6 months. Over the three years, observed incidences of malaria decreased by 60-98%. The prevalence of wild-type genotype for K13 molecular markers of artemisinin resistance was reported as remaining stable (39%; 249/631).

Antimalarial treatment was administered to entire communities living in a sub-population of 50 villages identified as malaria ‘hotspots’ where patients were often carrying malaria, but showed no signs of illness. Hotspot villages had a three times higher incidence of malaria than neighbouring villages. Early diagnosis and treatment was associated with a significant decrease in P falciparum incidence in hotspots (IRR 0·82, 95% CI 0·76–0·88 per quarter) and in other villages (0·75, 0·73–0·78 per quarter). Mass drug administration was associated with a five-times decrease in P falciparum incidence within hotspot villages (IRR 0·19, 95% CI 0·13–0·26).

This is an important study that demonstrates the potential to prevent or slow the spread of drug-resistant malaria by giving anti-malarial treatments to those living in malaria hotspots, together with support from community-based clinics. The emergence of resistance to the most effective treatment is deeply worrying, and risks undoing years of progress in malaria elimination. We need to think about new ways to help augment public health measures and reduce the spread of drug resistant malaria, particularly in South-East Asia” says Michael Chew, Science Portfolio Advisor, Wellcome Infection and Immunology Team.

As anti-malaria resistance continues to advance across South-East Asia, and could emerge or spread into Africa, study co-author Gilles Delmas, Director of the METF, suggests “Careful planning and public engagement to get the support of affected communities is key to ensure success. Our study shows that we can eliminate malaria even in remote areas. But long-term political and financial support will be needed to prevent malaria from returning.”

Effective malaria elimination will also rely on consistent tracking of drug resistance, using mapping tools such as those provided by the World Health Organisation and WWARN. Sharing data and pooling analyses to provide evidence on the performance of ACTs through WWARN Study Groups, together with consistent use of the CDISC Malaria Therapeutic Area User Guide (TAUG-Malaria), will help researchers in endemic countries to provide valuable evidence to combat this deadly disease.

Whilst this study covered 18,000km2 area, the authors conclude that more studies are needed before rolling-out this strategy into other parts of South-East Asia. This ambitious research group has shown that eliminating malaria is possible, if we deliver bold and urgent approaches in the field.

Read the full paper: Landier et al. Effect of generalised access to early diagnosis and treatment and targeted mass drug administration on Plasmodium falciparum malaria in Eastern Myanmar: an observational study of a regional elimination programme. The Lancet. Published online 24 April 2018.

The study was funded by The Bill and Melinda Gates Foundation, The Global Fund, and the Wellcome Trust, and organised by the SMRU-based Malaria Elimination Task Force (METF) in close collaboration with local health authorities.

SMRU Malaria Elimination Task Force (METF) health workers examine a map of local malaria hotspots and village clinics in eastern Myanmar. Photo by Alexander Kumar © 2018 MORU. A boat approaches one of the eastern Myanmar villages where the SMRU Malaria Elimination Task Force (METF) has set up a malaria treatment clinic. Photo by Alexander Kumar © 2018 MORU  Waiting room of Wang Pha clinic, located on the Thai–Myanmar border run by Shoklo Malaria Research Unit. Photo by Alexander Kumar © 2018 MORU
SMRU Malaria Elimination Task Force (METF) health workers examine a map of local malaria hotspots and village clinics in eastern Myanmar (left), A boat approaches one of the eastern Myanmar villages where the SMRU Malaria Elimination Task Force (METF) has set up a malaria treatment clinic (middle), Waiting room of Wang Pha clinic, located on the Thai–Myanmar border run by Shoklo Malaria Research Unit (right). Photos by Alexander Kumar © 2018 MORU

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