Anopheles Vectors in Mainland China While Approaching Malaria Elimination

Locally manufactured malaria RDTs for Plasmodium vivax: A comparative study of kits approved by National Medical Products Administration in China

PURPOSE

Early and accurate detection of Plasmodium vivax malaria cases is essential for preventing the re-establishment of malaria transmission in China, given the widespread distribution of Anopheles vectors that transmit vivax malaria. In this study, we aimed to compare the performance of three different commercial malaria rapid diagnostic test (RDT) kits for screening P. vivax in China.

METHODS

Microscopy was utilized to identify malaria parasites and to determine their parasite density levels. For the validation of microscopic findings and the genetic characterization of Plasmodium species, a nested polymerase chain reaction (PCR) technique was used. The Malaria RDT kits used in the present study encompassed products from BioPerfectus, which are designed for the detection of P. falciparum and other Plasmodium species, and kits from BlueCROSS and EGENS, tailored for the concurrent detection of P. falciparum and P. vivax.

RESULTS

As a result, the overall agreement between malaria RDTs and nested PCR was almost perfect, with kappa values as follows: BioPerfectus (κ = 1.000), BlueCROSS (κ = 0.975, 95 % CI 0.971-0.979), and EGENS (κ = 0.950, 95 % CI 0.941-0.959). However, there was a statistically significant difference in the detection rate of P. vivax-positive samples from 94.5 % (104/110) to 100 % (P = 0.047). Furthermore, the agreement between the BlueCROSS and EGENS kits for detecting P. vivax-specific pLDH was almost perfect (P = 0.499, κ 0.973, 95 % CI 0.968-0.978), while the detection rates were lower for samples with low parasite densities (BlueCROSS: P = 0.007; EGENS: P = 0.001).

CONCLUSIONS

The detection capacity of the existing P. vivax-specific RDT kits in China needs to be further improved.

Regional heterogeneity of malaria healthcare seeking and diagnosis in China (2017-2022): Implications in preventing re-establishment of malaria transmission

BACKGROUND

Enhancing regional collaboration in malaria prevention and control is a pivotal strategy for malaria control and elimination in China. The objective of this study is to examine the regional heterogeneity of malaria healthcare-seeking behaviors and diagnosis across various regions in China from 2017 to 2022.

METHODS

Individual case data from national malaria surveillance databases were utilized. An analysis was conducted to discern the regional variations in the healthcare-seeking behaviors and diagnosis among regions.

RESULTS

From 2017 to 2022, a total of 10,943 malaria cases were reported in China, predominantly imported cases (10,929), with significant variations in the distribution of different Plasmodium species among regions (P < 0.001) and annually (P < 0.001). There was a notable lack of timeliness in healthcare seeking (56.1 %) and case confirmation (67.3 %) with substantial regional disparities (P < 0.001). These delays predominantly occurred in county and prefectural-level medical institutions (P < 0.001), where misidentification of Plasmodium species was also prevalent (P < 0.001). Furthermore, an initial diagnosis of malaria was observed in 76.6 % of cases (P < 0.001), yet 87.8 % of malaria cases were ultimately confirmed correctly (P < 0.001). Notably, P. ovale (21.0 %) and P. malariae (10.8 %) were easily misidentified as P. vivax (P < 0.001).

CONCLUSION

The development of regional-specific interventions is essential to raise public awareness regarding malaria-related knowledge and to enhance the vigilance of health workers and their capacity of malaria testing. This will strengthen the nation's malaria surveillance and response system. Concurrently, fostering technological innovations for the rapid and precise identification of Plasmodium species, along with effective coordination of cross-regional mechanisms, is imperative to prevent re-establishment of malaria transmission in China.

Two Nested Inversions in the X Chromosome Differentiate the Dominant Malaria Vectors in Europe, Anopheles atroparvus and Anopheles messeae

The Maculipennis subgroup of malaria mosquitoes includes both dominant malaria vectors and non-vectors in Eurasia. Understanding the genetic factors, particularly chromosomal inversions, that differentiate Anopheles species can provide valuable insights for vector control strategies. Although autosomal inversions between the species in this subgroup have been characterized based on the chromosomal banding patterns, the number and positions of rearrangements in the X chromosome remain unclear due to the divergent banding patterns. Here, we identified two large X chromosomal inversions, approximately 13 Mb and 10 Mb in size, using fluorescence in situ hybridization. The inversion breakpoint regions were mapped by hybridizing 53 gene markers with polytene chromosomes of An. messeae. The DNA probes were designed based on gene sequences from the annotated An. atroparvus genome. The two nested inversions resulted in five syntenic blocks. Only two small syntenic blocks, which encompass 181 annotated genes in the An. atroparvus genome, changed their position and orientation in the X chromosome. The analysis of the An. atroparvus genome revealed an enrichment of gene ontology terms associated with immune system and mating behavior in the rearranged syntenic blocks. Additionally, the enrichment of DNA transposons was found in sequences homologous to three of the four breakpoint regions. This study demonstrates the successful application of the physical genome mapping approach to identify rearrangements that differentiate species in insects with polytene chromosomes.

Vector Biology and Integrated Management of Malaria Vectors in China

Malaria is an infectious disease caused by Plasmodium parasites, transmitted by Anopheles sinensis, Anopheles lesteri, Anopheles minimus, and Anopheles dirus in China. In 2021, the disease was eliminated in China after more than 70 years of efforts implementing an integrated mosquito management strategy. This strategy comprised indoor residual spray, insecticide-treated bed nets, irrigation management, and rice-fish coculture based on an understanding of taxonomic status and ecological behaviors of vector species, in conjunction with mass drug administration and promotion of public education. However, China still faces postelimination challenges, including the importation of approximately 2,000-4,000 cases of malaria into the country each year, as well as widespread resistance to pyrethroid insecticides in An. sinensis; these challenges require long-term vector surveillance to understand the distribution, population density, and development of resistance in vector mosquitoes to prevent local epidemics caused by imported malaria cases.

Seasonal prediction of the distribution of three major malaria vectors in China: Based on an ecological niche model

Against the backdrop of a global malaria epidemic that remains severe, China has eradicated indigenous malaria but still has to be alert to the risk of external importation. Understanding the distribution of vectors can provide an adequate and reliable basis for the development and implementation of vector control strategies. However, with the decline of malaria prevalence in recent years, the capacity of vector monitoring and identification has been greatly weakened. Here we have used new sampling records, climatic data, and topographic data to establish ecological niche models of the three main malaria vectors in China. The model results accurately identified the current habitat suitability areas for the three species of Anopheles and revealed that in addition to precipitation and temperature as important variables affecting the distribution of Anopheles mosquitoes, topographic variables also influenced the distribution of Anopheles mosquitoes. Anopheles sinensis is the most widespread malaria vector in China, with a wide region from the northeast (Heilongjiang Province) to the southwest (Yunnan Province) suitable for its survival. Suitable habitat areas for Anopheles lesteri are concentrated in the central, eastern, and southern regions of China. The suitable habitat areas of Anopheles minimus are the smallest and are only distributed in the border provinces of southern China. On this basis, we further assessed the seasonal variation in habitat suitability areas for these three major malaria vectors in China. The results of this study provide new and more detailed evidence for vector monitoring. In this new era of imported malaria prevention in China, regular reassessment of the risk of vector transmission is recommended.

Increasing incidence of Plasmodium ovale and persistent reporting of Plasmodium vivax in imported malaria cases: an analysis of 9-year surveillance data in four areas of China

Background

This study aimed at exploring the epidemiological pattern of imported malaria in China before malaria elimination in 2021, to provide evidence-based data for preventing malaria re-establishment in China.

Methods

Nine-year surveillance data on imported malaria in four provincial-level administrative divisions (PLADs) (Anhui, Chongqing, Guangxi, and Zhejiang) between 2011 and 2019 were thoroughly collected and analyzed.

Results

A quite stable trend in imported malaria cases between 2011 and 2019 was observed. In total, 6,064 imported patients were included. Plasmodium falciparum was the most frequently reported species (4,575, 75.6%). Cases of malaria were most frequently imported from Western Africa (54.4%). We identified an increasing trend in P. ovale and a persistence of P. vivax infections among the cases of malaria imported from Western Africa. Most patients (97.5%) were 20-50 years old. Among imported malaria infections, the main purposes for traveling abroad were labor export (4,914/6,064, 81.0%) and business trips (649, 10.7%). Most patients (2,008/6,064, 33.1%) first visited county-level medical institutions when they sought medical help in China. More patients were diagnosed within 3 days after visiting Centers for Disease Control and Prevention (CDCs) or entry-exit quarantine facilities (EQFs) (1,147/1609, 71.3%) than after visiting medical institutions (2,182/3993, 54.6%).

Conclusion

Imported malaria still poses a threat to the malaria-free status of China. County-level institutions are the primary targets in China to improve the sensitivity of the surveillance system and prevent the re-establishment of malaria. Health education should focus on exported labors, especially to Western and Central Africa. Increasing trend in P. ovale and persistence of P. vivax infections indicated their underestimations in Western Africa. Efficient diagnostic tools and sensitive monitoring systems are required to identify Plasmodium species in Africa.

Imported malaria from land bordering countries in China: A challenge in preventing the reestablishment of malaria transmission

OBJECTIVE

No indigenous malaria cases have been reported since 2017 in China, but a large number of imported cases are still reported every year, including those from the land bordering countries. To characterize their epidemiological profiles will provide evidence for the development of appropriate strategies to effectively address the challenges of border malaria in the post-elimination phase.

METHODS

Individual-level data of imported malaria cases from the land bordering countries were collected from 2017 to 2021 in China via the web-based surveillance systems, and analyzed by SPSS, ArcGIS and WPS software, to explore their epidemiological profiles.

RESULTS

A total of 1170 malaria cases imported into China from six of the fourteen land bordering countries were reported between 2017 and 2021 with a decline trend. Overall, cases were widely distributed in 31-97 counties from 11 to 21 provinces but mainly in Yunnan. Moreover, these imported cases were mainly infected with P. vivax (94.8%), and a total of 68 recurrent cases were reported in 6-14 counties from 4 to 8 provinces. In addition, nearly 57.1% of the total reported cases could seek healthcare within 2 days of getting sick, and 71.3% of the reported cases could be confirmed as malaria on the day they sought medical care.

CONCLUSIONS

China still needs to attach great importance to the risk and challenge of the imported malaria from bordering countries particularly from Myanmar in preventing reestablishment of malaria transmission in the post-elimination phase. It is necessary not only to strengthen collaboration and cooperation with the bordering countries, but also coordinate multiple departments at home to improve malaria surveillance and response system and prevent the reestablishment of malaria transmission in China.

Traditional Beliefs, Practices, and Migration: A Risk to Malaria Transmission in Rural Nepal

The study aimed to explore sociocultural factors influencing the risk of malaria and practices and beliefs towards malaria prevention, transmission and treatment in a remote village in Khatyad Rural Municipality (KRM) of Nepal. A sequential exploratory mixed methods approach was used. Qualitative data were collected through 25 one-on-one, in-depth interviews followed by a face-to-face household survey (n = 218) among people from a village in KRM believed to have a high risk of malaria. Traditional practices such as Chhaupadi requiring the seclusion of women during menstruation and post-partum, transhumance, and reliance on traditional healers for the management of malaria were common practices in the village. The household survey found 98.1% of women faced menstrual exile either inside the house or in a separate hut, with 64.2% not having access to Long-lasting Insecticidal Nets (LLINs). Hardships and economic constraints compelled villagers to migrate seasonally for work to malaria-endemic areas in India, thereby exposing themselves to the risk of malaria. Persistent traditional beliefs and seasonal migration could threaten the elimination goals set by the national malaria program.

Establishing and applying an adaptive strategy and approach to eliminating malaria: practice and lessons learnt from China from 2011 to 2020

ABSTRACTOn 30 June 2021, China was certified malaria-free by the World Health Organization. In this study, the evolution, performance, outcomes, and impact of China's adaptive strategy and approach for malaria elimination from 2011 to 2020 were analysed using 10-year data. The strategy and approach focused on timely detection and rapid responses to individual cases and foci. Indigenous cases declined from 1,308 in 2011 to 36 in 2015, and the last one was reported from Yunnan Province in April 2016, although thousands of imported cases still occur annually. The "1-3-7" approach was implemented successfully between 2013 and 2020, with 100% of cases reported within 24 h, 94.5% of cases investigated within three days of case reporting, and 93.4% of foci responses performed within seven days. Additionally, 81.6% of patients attended the first healthcare visit within 1-3 days of onset and 58.4% were diagnosed as malaria within three days of onset, in 2017-2020. The adaptive strategy and approach, along with their universal implementation, are most critical in malaria elimination. In addition to strengthening surveillance on drug resistance and vectors and border malaria collaboration, a further adapted three-step strategy and the corresponding "3-3-7" model are recommended to address the risks of re-transmission and death by imported cases after elimination. China's successful practice and lessons learnt through long-term efforts provide a reference for countries moving towards elimination.

The control of malaria vectors in rice fields: a systematic review and meta-analysis

The relatively stable aquatic conditions of irrigated lowland and rainfed rice, which is grown across 145 million hectares in more than 100 countries, are capable of generating large numbers of mosquito vectors of malaria, which causes more than 400,000 deaths per year worldwide. Many methods can control these vectors, but a systematic review has not previously been conducted. This study assesses whether larviciding, fish or intermittent irrigation can significantly reduce malaria vectors in rice fields whilst increasing rice yield. After a literature search for studies reporting the effect of larval control and rice cultivation practices on malaria vector densities in rice fields, 33 studies were eligible for meta-analysis. Larviciding was effective at reducing rice-field malaria vectors. Pooled analysis of five controlled time-series (CTS) studies with chemical insecticides showed an overall combined reduction of larval densities of 77% compared to no larviciding. Eight CTSs with biological larvicides showed a pooled reduction of 60% compared to no larviciding. Cultivating rice and fish together provided good control too: a pooled analysis of three CTSs showed an overall 82% reduction in anopheline larvae compared to no fish. Pooled analysis of four studies suggested that intermittent irrigation (using various timings and frequencies of drainage) is effective at reducing the abundance of late-stage anopheline larvae (pooled reduction = - 35%), but not overall immature abundance, compared to continuous flooding. We conclude that many interventions such as larvicides, fish and intermittent irrigation can provide riceland malaria vector control, but the critical obstacle to wider use is farmer acceptability. Future research should be led by the agricultural sector, with inputs from entomologists, to investigate malaria control co-benefits within high-yielding rice cultivation practices.

CRISPR/Cas9 mediates efficient site-specific mutagenesis of the odorant receptor co-receptor (Orco) in the malaria vector Anopheles sinensis

BACKGROUND

Anopheles sinensis is the most widely distributed mosquito species and is the main transmitter of Plasmodium vivax malaria in China. Most previous research has focused on the mechanistic understanding of biological processes in An. sinensis and novel ways of interrupting malaria transmission. However, the development of functional genomics and genetics-based vector control strategies against An. sinensis remain limited because of insufficient site-specific genome editing tools.

RESULTS

We report the first successful application of the CRISPR/Cas9 mediated knock-in for highly efficient, site-specific mutagenesis in An. sinensis. The EGFP marker gene driven by the 3 × P3 promoter was precisely integrated into the odorant receptor co-receptor (Orco) by direct injections of Cas9 protein, double-stranded DNA donor, and Orco-gRNA. We achieved a mutation rate of 3.77%, similar to rates in other mosquito species. Precise knock-in at the intended locus was confirmed by polymerase chain reaction (PCR) amplification and sequencing. The Orco mutation severely impaired mosquito sensitivity to some odors and their ability to locate and discriminate a human host.

CONCLUSION

Orco was confirmed as a key mediator of multiple olfactory-driven behaviors in the An. sinensis life cycle, highlighting the importance of Orco as a key molecular target for malaria control. The results also demonstrated that CRISPR/Cas9 was a simple and highly efficient genome editing technique for An. sinensis and could be used to develop genetic control tools for this vector. © 2022 Society of Chemical Industry.

Community structure and insecticide resistance of malaria vectors in northern-central Myanmar

BACKGROUND

Myanmar is one of the six countries in the Greater Mekong Subregion (GMS) of Southeast Asia. Malaria vectors comprise many Anopheles species, which vary in abundance and importance in malaria transmission among different geographical locations in the GMS. Information about the species composition, abundance, and insecticide resistance status of vectorial systems in Myanmar is scarce, hindering our efforts to effectively control malaria vectors in this region.

METHODS

During October and November 2019, larvae and adult females of Anopheles mosquitoes were collected in three sentinel villages of Banmauk township in northern Myanmar. Adult female mosquitoes collected by cow-baited tent collection (CBTC) and adults reared from field-collected larvae (RFCL) were used to determine mortality rates and knockdown resistance (kdr) against deltamethrin using the standard WHO susceptibility test. Molecular species identification was performed by multiplex PCR and ITS2 PCR, followed by DNA sequencing. The kdr mutation at position 1014 of the voltage-gated sodium channel gene was genotyped by DNA sequencing for all Anopheles species tested.

RESULTS

A total of 1596 Anopheles mosquitoes from seven morphologically identified species groups were bioassayed. Confirmed resistance to deltamethrin was detected in the populations of An. barbirostris (s.l.), An. hyrcanus (s.l.), and An. vagus, while possible resistance was detected in An. annularis (s.l.), An. minimus, and An. tessellatus. Anopheles kochi was found susceptible to deltamethrin. Compared to adults collected by CBTC, female adults from RFCL had significantly lower mortality rates in the four species complexes. A total of 1638 individuals from 22 Anopheles species were molecularly identified, with the four most common species being An. dissidens (20.5%) of the Barbirostris group, An. peditaeniatus (19.4%) of the Hyrcanus group, An. aconitus (13.4%) of the Funestus group, and An. nivipes (11.5%) of the Annularis group. The kdr mutation L1014F was only detected in the homozygous state in two An. subpictus (s.l.) specimens and in a heterozygous state in one An. culicifacies (s.l.) specimen.

CONCLUSIONS

This study provides updated information about malaria vector species composition and insecticide resistance status in northern Myanmar. The confirmed deltamethrin resistance in multiple species groups constitutes a significant threat to malaria vector control. The lack or low frequency of target-site resistance mutations suggests that other mechanisms are involved in resistance. Continual monitoring of the insecticide resistance of malaria vectors is required for effective vector control and insecticide resistance management.

Genome-wide identification and expression profiling of odorant receptor genes in the malaria vector Anopheles sinensis

Background

The olfactory system plays a crucial role in regulating insect behaviors. The detection of odorants is mainly mediated by various odorant receptors (ORs) that are expressed in the dendrites of olfactory neurons of chemosensilla. Anophelessinensis is a major malaria vector in Eastern Asia and its genome has recently been successfully sequenced and annotated. In this study, we present genome-wide identification and expression profiling of OR genes in different chemosensory tissues of An.sinensis.

Methods

The OR genes were identified using the available genome sequences of An.sinensis. A series of bioinformatics analyses were conducted to investigate the structure, genome distribution, selective pressure and phylogenetic relationships of OR genes, the conserved domains and specific functional sites in the OR amino acid sequences. The expression levels of OR genes were analyzed from transcriptomic data from An.sinensis antennae, proboscis and maxillary palps of both sexes.

Results

A total of 59 putative OR genes have been identified and characterized in An.sinensis. This number is significantly less than that in An.gambiae. Whether this difference is caused by the contraction or expansion of OR genes after divergence of the two species remains unknown. The RNA-seq analysis showed that AsORs have obvious tissue- and sex-specific expression patterns. Most AsORs are highly expressed in the antennae and the expression pattern and number of AsORs expressed in antennae are similar in males and females. However, the relative levels of AsOR transcripts are much higher in female antennae than in male antennae, which indicates that the odor sensitivity is likely to be increased in female mosquitoes. Based on the expression patterns and previous studies, we have speculated on the functions of some OR genes but this needs to be validated by further behavioral, molecular and electrophysiological studies. Further studies are necessary to compare the olfactory-driven behaviors and identify receptors that respond strongly to components of human odors that may act in the process of human recognition.

Conclusions

This is the first genome-wide analysis of the entire repertoire of OR genes in An.sinensis. Characterized features and profiled expression patterns of ORs suggest their involvement in the odorous reception of this species. Our findings provide a basis for further research on the functions of OR genes and additional genetic and behavioral targets for more sustainable management of An.sinensis in the future.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05259-x.

Profiling of Transcriptome-Wide N6-Methyladenosine (m6A) Modifications and Identifying m6A Associated Regulation in Sperm Tail Formation in Anopheles sinensis

Recent discoveries of reversible N6-methyladenosine (m6A) methylation on messenger RNA (mRNA) and mapping of m6A methylomes in many species have revealed potential regulatory functions of this RNA modification by m6A players—writers, readers, and erasers. Here, we first profile transcriptome-wide m6A in female and male Anopheles sinensis and reveal that m6A is also a highly conserved modification of mRNA in mosquitoes. Distinct from mammals and yeast but similar to Arabidopsis thaliana, m6A in An. sinensis is enriched not only around the stop codon and within 3′-untranslated regions but also around the start codon and 5′-UTR. Gene ontology analysis indicates the unique distribution pattern of m6A in An. sinensis is associated with mosquito sex-specific pathways such as tRNA wobble uridine modification and phospholipid-binding in females, and peptidoglycan catabolic process, exosome and signal recognition particle, endoplasmic reticulum targeting, and RNA helicase activity in males. The positive correlation between m6A deposition and mRNA abundance indicates that m6A can play a role in regulating gene expression in mosquitoes. Furthermore, many spermatogenesis-associated genes, especially those related to mature sperm flagellum formation, are positively modulated by m6A methylation. A transcriptional regulatory network of m6A in An. sinensis is first profiled in the present study, especially in spermatogenesis, which may provide a new clue for the control of this disease-transmitting vector.

Mapping the Distributions of Mosquitoes and Mosquito-Borne Arboviruses in China

The geographic expansion of mosquitos is associated with a rising frequency of outbreaks of mosquito-borne diseases (MBD) worldwide. We collected occurrence locations and times of mosquito species, mosquito-borne arboviruses, and MBDs in the mainland of China in 1954−2020. We mapped the spatial distributions of mosquitoes and arboviruses at the county level, and we used machine learning algorithms to assess contributions of ecoclimatic, socioenvironmental, and biological factors to the spatial distributions of 26 predominant mosquito species and two MBDs associated with high disease burden. Altogether, 339 mosquito species and 35 arboviruses were mapped at the county level. Culex tritaeniorhynchus is found to harbor the highest variety of arboviruses (19 species), followed by Anopheles sinensis (11) and Culex pipiens quinquefasciatus (9). Temperature seasonality, annual precipitation, and mammalian richness were the three most important contributors to the spatial distributions of most of the 26 predominant mosquito species. The model-predicted suitable habitats are 60–664% larger in size than what have been observed, indicating the possibility of severe under-detection. The spatial distribution of major mosquito species in China is likely to be under-estimated by current field observations. More active surveillance is needed to investigate the mosquito species in specific areas where investigation is missing but model-predicted probability is high.

Prevalence of antifolate drug resistance markers in Plasmodium vivax in China

The dihydrofolate reductase (dhfr) and dihydropteroate synthetase (dhps) genes of Plasmodium vivax, as antifolate resistance-associated genes were used for drug resistance surveillance. A total of 375 P. vivax isolates collected from different geographical locations in China in 2009-2019 were used to sequence Pvdhfr and Pvdhps. The majority of the isolates harbored a mutant type allele for Pvdhfr (94.5%) and Pvdhps (68.2%). The most predominant point mutations were S117T/N (77.7%) in Pvdhfr and A383G (66.8%) in Pvdhps. Amino acid changes were identified at nine residues in Pvdhfr. A quadruple-mutant haplotype at 57, 58, 61, and 117 was the most frequent (57.4%) among 16 distinct Pvdhfr haplotypes. Mutations in Pvdhps were detected at six codons, and the double-mutant A383G/A553G was the most prevalent (39.3%). Pvdhfr exhibited a higher mutation prevalence and greater diversity than Pvdhps in China. Most isolates from Yunnan carried multiple mutant haplotypes, while the majority of samples from temperate regions and Hainan Island harbored the wild type or single mutant type. This study indicated that the antifolate resistance levels of P. vivax parasites were different across China and molecular markers could be used to rapidly monitor drug resistance. Results provided evidence for updating national drug policy and treatment guidelines.

Identification and phylogenetic analysis of voltage-gated sodium channel haplotypes in the malaria vector Anopheles sinensis using a high-throughput amplicon sequencing approach

Background

Anopheles sinensis is a dominant vector for malaria transmission in Asian countries. Voltage-gated sodium channel (VGSC) mutation-mediated knock-down resistance (kdr) has developed in many A. sinensis populations because of intensive and long-term use of pyrethroids. Our previous study showed that multiple mutations at position 1014 of the VGSC were heterogeneously distributed in A. sinensis populations across Sichuan, China.

Methods

To understand resistance genotypes at the haplotype level and reconstruct the phylogenetic relationship of VGSC haplotypes, a cost-effective next-generation sequencing (NGS)-based amplicon sequencing approach was established to clarify haplotypes containing codon 1014 of the VGSC gene from a total of 446 adults collected in 12 locations of Sichuan, China.

Results

Nineteen (19) haplotypes were identified, including 11 wild 1014L, 6 resistance 1014F, and 2 resistance 1014C haplotypes. We found that resistance haplotypes of A. sinensis VGSC were widely distributed at frequencies ranging from 3.67 to 92.61%. The frequencies of the 1014C haplotype in the southeast of Sichuan (Luzhou, Guangan, and Suining) were relatively higher than those in other sampling locations. Phylogenetic analyses support that kdr-type mutation at position 1014 is not singly originated and resistance 1014C haplotypes evolve from TTT-encoding 1014F.

Conclusions

A cost-effective next-generation sequencing (NGS)-based amplicon sequencing approach has been established in this study. The data revealed the patchy distribution of VGSC resistance haplotypes with overall high frequencies in Sichuan, China. Phylogenetic analyses support multiple origins and sequential evolution (1014L → 1014F → 1014C) for kdr-type mutations in A. sinensis.

Graphical abstract

Surveillance of Malaria Vectors - 18 Sites, 12 PLADs, China, 2018-2020

What is already known on this topic?

Malaria is an infectious parasitic disease transmitted by the bite of Anopheles mosquitoes and is a serious threat to human health. Surveillance of malaria vectors is part of the integrated strategy for malaria elimination in China.

What is added by this report?

This research supplements the population distribution, density, and seasonal fluctuation of malaria vectors in the Anopheles surveillance sites from 2018 to 2020 in China.

What are the implications for public health practice?

Continuous surveillance of malaria vectors is important for maintaining malaria-free status in China and for providing a scientific basis for risk assessment of malaria retransmission.

The mechanisms of action of Plasmodium infection against cancer

Our murine cancer model studies have demonstrated that Plasmodium infection activates the immune system that has been inhibited by cancer cells, counteracts tumor immunosuppressive microenvironment, inhibits tumor angiogenesis, inhibits tumor growth and metastasis, and prolongs the survival time of tumor-bearing mice. Based on these studies, three clinical trials of Plasmodium immunotherapy for advanced cancers have been approved and are ongoing in China. After comparing the mechanisms of action of Plasmodium immunotherapy with those of immune checkpoint blockade therapy, we propose the notion that cancer is an ecological disease and that Plasmodium immunotherapy is a systemic ecological counterattack therapy for this ecological disease, with limited side effects and without danger to public health based on the use of artesunate and other measures. Recent reports of tolerance to treatment and limitations in majority of patients associated with the use of checkpoint blockers further support this notion. We advocate further studies on the mechanisms of action of Plasmodium infection against cancer and investigations on Plasmodium-based combination therapy in the coming future.

A retrospective analysis of malaria epidemiological characteristics in Yingjiang County on the China-Myanmar border

Yingjiang County, which is on the China–Myanmar border, is the main focus for malaria elimination in China. The epidemiological characteristics of malaria in Yingjiang County were analysed in a retrospective analysis. A total of 895 malaria cases were reported in Yingjiang County between 2013 and 2019. The majority of cases occurred in males (70.7%) and individuals aged 19–59 years (77.3%). Plasmodium vivax was the predominant species (96.6%). The number of indigenous cases decreased gradually and since 2017, no indigenous cases have been reported. Malaria cases were mainly distributed in the southern and southwestern areas of the county; 55.6% of the indigenous cases were reported in Nabang Township, which also had the highest risk of imported malaria. The “1–3–7” approach has been implemented effectively, with 100% of cases reported within 24 h, 88.9% cases investigated and confirmed within 3 days and 98.5% of foci responded to within 7 days. Although malaria elimination has been achieved in Yingjiang County, sustaining elimination and preventing the re-establishment of malaria require the continued strengthening of case detection, surveillance and response systems targeting the migrant population in border areas.

Multiplex PCR assay for the identification of eight Anopheles species belonging to the Hyrcanus, Barbirostris and Lindesayi groups

BACKGROUND

Genus Anopheles mosquitoes are the primary vectors of human malaria, which is a serious threat to public health worldwide. To reduce the spread of malaria and identify the malaria infection rates in mosquitoes, accurate species identification is needed. Malaria re-emerged in 1993 in the Republic of Korea (ROK), with numbers peaking in 2004 before decreasing to current levels. Eight Anopheles species (Anopheles sinensis, Anopheles pullus, Anopheles belenrae, Anopheles lesteri, Anopheles kleini, Anopheles sineroides, Anopheles koreicus, Anopheles lindesayi) are distributed throughout Korea. Members of the Anopheles Hyrcanus group currently cannot be identified morphologically. The other species of Anopheles can be identified morphologically, except when specimens are damaged in traps. The purpose of this study was to develop a rapid and accurate method for simultaneous molecular identification of the eight Anopheles species present in the ROK.

METHODS

Anopheles spp. used in this study were collected near/in the demilitarized zone in ROK, where most malaria cases are reported. DNA from 165 of the Anopheles specimens was used to develop a multiplex PCR assay. The internal transcribed spacer 2 (ITS2) region of each species was sequenced and analysed for molecular identification.

RESULTS

DNA from a total of 165 Anopheles specimens was identified to species using a multiplex diagnostic system. These included: 20 An. sinensis, 21 An. koreicus, 17 An. lindesayi, 25 An. kleini, 11 An. lesteri, 22 An. sineroides, 23 An. belenrae, and 26 An. pullus. Each species was clearly distinguished by electrophoresis as follows: 1,112 bp for An. sinensis; 925 bp for An. koreicus; 650 bp for An. lindesayi; 527 bp for An. kleini; 436 bp for An. lesteri; 315 bp for An. sineroides; 260 bp for An. belenrae; and, 157 bp for An. pullus.

CONCLUSION

A multiplex PCR assay was developed to identify Anopheles spp. distributed in ROK. This method can be used to accurately identify Anopheles species that are difficult to identify morphologically to determine species distributions and malaria infection rates.

Increasing proportions of relapsing parasite species among imported malaria in China's Guangxi Province from Western and Central Africa

BACKGROUND

Travel-related malaria in non-endemic areas returning from endemic areas presents important challenges to diagnosis and treatment. Imported malaria to newly malaria-free countries poses further threats of malaria re-introduction and potential resurgence. For those traveling to places with high Plasmodium falciparum prevalence, prophylaxis against this parasite is recommended, whereas causal prophylaxis against relapsing malaria is often overlooked.

METHODS

We analyzed a cluster of imported malaria among febrile patients in Shanglin County, Guangxi Province, China, who had recent travel histories to Western and Central Africa. Malaria was diagnosed by microscopy and subsequently confirmed by species- and subspecies-specific PCR. Plasmodium vivax was genotyped using a barcode consisting of 42 single nucleotide polymorphisms.

RESULTS

Investigations of 344 PCR-confirmed malaria cases revealed that in addition to Plasmodium falciparum being the major parasite species, the relapsing parasites Plasmodium ovale and P. vivax accounted for ~40% of these imported cases. Of the 114 P. ovale infections, 65.8% and 34.2% were P. ovale curtisi and P. ovale wallikeri, respectively, with the two subspecies having a ~2:1 ratio in both Western and Central Africa. Phylogenetic analysis of 14 P. vivax isolates using a genetic barcode demonstrated that 11 formed a distinct clade from P. vivax populations from Eastern Africa.

CONCLUSION

This study provides support for active P. vivax transmission in areas with the predominant Duffy-negative blood group. With relapsing malaria making a substantial proportion of the imported malaria, causal prophylaxis should be advocated to travelers with a travel destination to Western and Central Africa.

A survey of insecticide resistance-conferring mutations in multiple targets in Anopheles sinensis populations across Sichuan, China

Background

Sichuan province is located in the southwest of China, and was previously a malaria-endemic region. Although no indigenous malaria case has been reported since 2011, the number of imported cases is on the rise. Insecticide-based vector control has played a central role in the prevention of malaria epidemics. However, the efficacy of this strategy is gravely challenged by the development of insecticide resistance. Regular monitoring of insecticide resistance is essential to inform evidence-based vector control. Unfortunately, almost no information is currently available on the status of insecticide resistance and associated mechanisms in Anopheles sinensis, the dominant malaria vector in Sichuan. In this study, efforts were invested in detecting the presence and frequency of insecticide resistance-associated mutations in three genes that encode target proteins of several classes of commonly used insecticides.

Methods

A total of 446 adults of An. sinensis, collected from 12 locations across Sichuan province of China, were inspected for resistance-conferring mutations in three genes that respectively encode acetylcholinesterase (AChE), voltage-gated sodium channel (VGSC), and GABA receptor (RDL) by DNA Sanger sequencing.

Results

The G119S mutation in AChE was detected at high frequencies (0.40–0.73). The predominant ace-1 genotype was GGC/AGC (119GS) heterozygotes. Diverse variations at codon 1014 were found in VGSC, leading to three different amino acid substitutions (L1014F/C/S). The 1014F was the predominant resistance allele and was distributed in all 12 populations at varying frequencies from 0.03 to 0.86. The A296S mutation in RDL was frequently present in Sichuan, with 296SS accounting for more than 80% of individuals in six of the 12 populations. Notably, in samples collected from Chengdu (DJY) and Deyang (DYMZ), almost 30% of individuals were found to be resistant homozygotes for all three targets.

Conclusions

Resistance-related mutations in three target proteins of the four main classes of insecticides were prevalent in most populations. This survey reveals a worrisome situation of multiple resistance genotypes in Sichuan malaria vector. The data strengthen the need for regular monitoring of insecticide resistance and establishing a region-customized vector intervention strategy.

Graphical abstract

Spatial patterns of <em>Plasmodium vivax</em> transmission explored by multivariate auto-regressive state-space modelling - A case study in Baoshan Prefecture in southern China

The transition from the control phase to elimination of malaria in China through the national malaria elimination programme has focussed attention on the need for improvement of the surveillance- response systems. It is now understood that routine passive surveillance is inadequate in the parasite elimination phase that requires supplementation by active surveillance in foci where cluster cases have occurred. This study aims to explore the spatial clusters and temporal trends of malaria cases by the multivariate auto-regressive state-space model (MARSS) along the border to Myanmar in southern China. Data for indigenous cases spanning the period from 2007 to 2010 were extracted from the China's Infectious Diseases Information Reporting Management System (IDIRMS). The best MARSS model indicated that malaria transmission in the study area during 36 months could be grouped into three clusters. The estimation of malaria transmission patterns showed a downward trend across all clusters. The proposed methodology used in this study offers a simple and rapid, yet effective way to categorize patterns of foci which provide assistance for active monitoring of malaria in the elimination phase.

The Microbiota of Three Anopheles Species in China

Microbiota are vital for the development, physiology, and vectorial capacity of mosquitoes. The composition and role of microbiota in Anopheles species, especially Anopheles gambiae and Anopheles stephensi, have been extensively studied, but little is known about the microbiota of Anopheles species in China. We characterized the microbial communities of Anopheles dirus, Anopheles sinensis, and Anopheles lesteri by 16S rRNA sequencing. There were distinct differences in the composition of microbiota in An. lesteri and the other 2 species. The discriminatory genera in the 3 species were analyzed by the linear discriminant analysis effect size method. Our results provide an overview of the population structure of microbiota in 3 native Anopheles species and will pave the way for further understanding of their role in mosquito physiology and vector competence.

Species diversity and insecticide resistance within the Anopheles hyrcanus group in Ubon Ratchathani Province, Thailand

Background

Members of the Anopheles hyrcanus group have been incriminated as important malaria vectors. This study aims to identify the species and explore the insecticide susceptibility profile within the Anopheles hyrcanus group in Ubon Ratchathani Province, northeastern Thailand where increasing numbers of malaria cases were reported in 2014.

Methods

Between 2013 and 2015, five rounds of mosquito collections were conducted using human landing and cattle bait techniques during both the rainy and dry seasons. Anopheles mosquitoes were morphologically identified and their insecticide susceptibility status was investigated. Synergist bioassays were carried out with An. hyrcanus (s.l.) due to their resistance to all insecticides. An ITS2-PCR assay was conducted to identify to species the Hyrcanus group specimens.

Results

Out of 10,361 Anopheles females collected, representing 18 taxa in 2 subgenera, 71.8% were morphologically identified as belonging to the Hyrcanus Group (subgenus Anopheles), followed by An. barbirostris group (7.9%), An. nivipes (6.5%), An. philippinensis (5.9%) and the other 14 Anopheles species. Specimens of the Hyrcanus Group were more prevalent during the rainy season and were found to be highly zoophilic. Anopheles hyrcanus (s.l.) was active throughout the night, with an early peak of activity between 18:00 h and 21:00 h. ITS2-PCR assay conducted on 603 DNA samples from specimens within the Hyrcanus Group showed the presence of five sisters species. Anopheles peditaeniatus was the most abundant species (90.5%, n = 546), followed by An. nitidus (4.5%, n = 27), An. nigerrimus (4.3%, n = 26), An. argyropus (0.5%, n = 3), and An. sinensis (0.2%, n = 1). All An. hyrcanus (s.l.) specimens that were found resistant to insecticides (deltamethrin 0.05%, permethrin 0.75% and DDT 4% and synergist tests) belonged to An. peditaeniatus. The degree of resistance in An. peditaeniatus to each of these three insecticides was approximately 50%. Addition of PBO (Piperonyl butoxide), but not DEF (S.S.S-tributyl phosphotritioate), seemed to restore susceptibility, indicating a potential role of oxidases as a detoxifying enzyme resistance mechanism.

Conclusions

A better understanding of mosquito diversity related to host preference, biting activity and insecticide resistance status will facilitate the implementation of locally adapted vector control strategies.

Spatial heterogeneity and temporal dynamics of mosquito population density and community structure in Hainan Island, China

BACKGROUND

Mosquitoes are vectors of many tropical diseases. Understanding the ecology of local mosquito vectors, such as species composition, distributions, population dynamics, and species diversity is important for designing the optimal strategy to control the mosquito-borne diseases.

METHODS

Entomological surveillance of adult mosquitoes was conducted in five sites representing different ecological settings across Hainan Island from January to December of 2018 using BG Sentinel (BGS) traps and Centers for Disease Prevention and Control (CDC) light traps. In each site, we selected three areas representing urban, suburban and rural settings. Eighteen trap-days were sampled in each setting at each site, and CDC light traps and BGS traps were setup simultaneously. Mosquito species composition, distribution, population dynamics, and species diversity were analyzed. Mosquito densities were compared between different study sites and between different settings.

RESULTS

Nine species of mosquitoes belonging to four genera were identified. Culex quinquefasciatus (80.8%), Armigeres subalbatus (13.0%) and Anopheles sinensis (3.1%) were the top three species collected by CDC light traps; Cx. quinquefasciatus (91.9%), Ae. albopictus (5.1%), and Ar. subalbatus (2.8%) were the top three species collected by BGS traps. Predominant species varied among study sites. The population dynamics of Ae. albopictus, An. sinensis and Cx. quinquefasciatus showed clear seasonal variation regardless of study sites with a varied peak season for different species. Mosquito abundance of all species showed significant differences among different study sites and among urban, suburban and rural areas. Danzhou had the highest mosquito biodiversity, with an α, β, and Gini-Simpson biodiversity index of 8, 1.13 and 0.42, respectively. BGS traps captured Aedes mosquito at a higher efficiency than CDC light traps, whereas CDC light traps captured significantly more Anopheles and Armigeres mosquitoes than BGS traps.

CONCLUSIONS

Mosquitoes were abundant on Hainan Island with clear seasonality and spatial heterogeneity. Population density, species composition, distribution, and species diversity were strongly affected by the natural environment. Different tools are required for the surveillance of different mosquito species.

First molecular detection of Plasmodium relictum in Anopheles sinensis and Armigeres subalbatus

Background:

Plasmodium relictum is one of the most important avian malaria species, which is mainly seen in wild birds, with infections reported in more than 70 different species and at high prevalence.

Aim:

The aim of this study was to determine the molecular prevalence of Plasmodium spp. in mosquitoes collected in China.

Method:

A Plasmodium -specific fluorescence resonance energy transfer (FRET) polymerase chain reaction (PCR) was established in this study to analyze five species of mosquitoes (1,620 Culex pipiens pallens, 806 Aedes albopictus, 377 Armigeres subalbatus, 168 Anopheles sinensis, and 80 Culex tritaeniorhynchus) collected in hand nets from homes in 25 provinces of China.

Results:

Only females originated from six provinces were determined to be positive (0.6%, 10/1,809). Plasmodium species were detected in three mosquito species, such as C.pipiens pallens (0.5%, 8/1,620), A.sinensis (0.6%, 1/168), and A.subalbatus (0.3%, 1/377). Of the three mosquito species positive for P. relictum, only C. pipiens pallens is known to feed on birds and is recognized as the natural vector of P. relictum.

Conclusion:

This is the first time that P. relictum has been detected in A. sinensis and A. subalbatus. P. relictum, the agent of avian malaria, was present in mosquitoes in China, including mosquito species not previously thought to be the vectors.

Resistance to pyrethroid and organophosphate insecticides, and the geographical distribution and polymorphisms of target-site mutations in voltage-gated sodium channel and acetylcholinesterase 1 genes in Anopheles sinensis populations in Shanghai, China

Background

In the final phase of China’s national programme to eliminate malaria by 2020, it is vitally important to monitor the resistance of malaria vectors for developing effective vector control strategies. In 2017 Shanghai declared that it had eliminated malaria; however, the insecticide resistance status of the primary malaria vector Anopheles sinensis remains unknown.

Methods

We examined the pyrethroid and organophosphate resistance of An. sinensis via a bioassay of two populations from the Chongming District of Shanghai. The voltage-gated sodium channel (VGSC) and acetylcholinesterase 1 (ace-1) genes were partially sequenced to examine the association between resistance phenotype and target site genotype. In addition, the geographical distribution, polymorphism and genotype frequencies of insecticide resistance genes were examined using samples collected during routine mosquito surveillance in 2016 and 2017 from Chongming, Songjiang, Jiading and Qingpu Districts.

Results

In Chongming District, the An. sinensis population near Dongtan National Nature Reserve showed resistance to pyrethroids, sensitivity to organophosphate, no knockdown resistance (kdr) mutations in the VGSC gene, and a low frequency (1.71%) of the ace-1 119S allele. An An. sinensis population near the Chongming central area (CM-Xinhe population) showed high resistance to pyrethroids and organophosphates and high frequencies of kdr 1014F and 1014C (80.73%) and ace-1 119S (85.98%) alleles. A significant association was detected between the homozygous kdr mutation 1014F/1014F and pyrethroid resistance in the CM-Xinhe population, indicating that the kdr mutation is probably recessive. Eight kdr genotypes with 1014F and 1014C substitutions were detected in the four surveyed districts of Shanghai. TTT and GGC/AGC were the dominant kdr allele and ace-1 genotype, respectively, and were prevalent in most Shanghai An. sinensis populations.

Conclusions

On the basis of our assessment of insecticide resistance gene mutations in Shanghai, we identified a kdr mutation-free population in Chongming Dongtan. However, high frequencies of target-site mutations of insecticide resistance genes were observed in most areas of Shanghai. Bioassays of An. sinensis populations in the central Chongming District indicated the high insecticide resistance status of An. sinensis populations in Shanghai. We accordingly recommend a restriction on insecticide usage and development of effective integrated pest/vector management interventions to support disease control efforts.

Monitoring of malaria vectors at the China-Myanmar border while approaching malaria elimination

BACKGROUND

Tengchong County was one of the counties located at the China-Myanmar border with high malaria incidence in the previous decades. As the pilot county for malaria elimination at the border area, Tengchong County is aiming to be the first county to achieve malaria elimination goal. A cross-sectional entomological survey was carried out to evaluate the feasibility of elimination approach and assess the receptivity of malaria reintroduction.

METHODS

Light traps associated with live baits were used to investigate the abundance of adult mosquitoes in nine villages in Tengchong County. Light traps were set to collect adult mosquitoes in both human houses and cowsheds from dusk till dawn in each site.

RESULTS

A total of 4948 adult Anopheles mosquitoes were collected from May to December in two villages. Of the mosquitoes were captured, 24.2% were in human houses and 75.8% in cowsheds. The peak of abundance occurred in July for An. sinensis and in September-October for An. minimus (s.l.) Ten Anopheles species were collected, the most prevalent being An. sinensis (50.3%), An. peditaeniatus (31.6%) and An. minimus (s.l.) (15.8%), contributing to 97.6% of the sample. Potential breeding sites were also investigated and a total of 407 larvae were collected, with An. sinensis (50.1%) and An. minimus (s.l.) (46.2%) as predominant species. Ponds and rice fields were the two preferred breeding sites for Anopheles mosquitoes; however, the difference between the number of adults and larvae captured suggest other breeding sites might exist. Both An. sinensis and An. minimus (s.l.) were found zoophilic with human blood index as 0.21 and 0.26, respectively. No Plasmodium positive Anopheles specimens were found by PCR among 4,000 trapped mosquitoes.

CONCLUSIONS

Although no indigenous malaria cases have been reported in Tengchong County since 2013, there is still a risk from the presence of vectors in the context of human population movements from neighboring malaria endemic areas. The presence of An. sinensis, associated to rice fields, is particularly worrying. Sustained entomological surveillance is strongly suggested even after malaria elimination certification.

Projecting potential spatial and temporal changes in the distribution of Plasmodium vivax and Plasmodium falciparum malaria in China with climate change

BACKGROUND

Global climate change is likely to increase the geographic range and seasonality of malaria transmission. Areas suitable for distribution of malaria vectors are predicted to increase with climate change but evidence is limited on future distribution of malaria with climate in China.

OBJECTIVE

Our aim was to assess a potential effect of climate change on Plasmodium vivax (P. vivax) and Plasmodium falciparum (P. falciparum) malaria under climate change scenarios.

METHODS

National malaria surveillance data during 2005-2014 were integrated with corresponding climate data to model current weather-malaria relationship. We used the Generalized Additive Model (GAM) with a spatial component, assuming a quasi-Poisson distribution and including an offset for the population while accounting for potential non-linearity and long-term trend. The association was applied to future climate to project county-level malaria distribution using ensembles of Global Climate Models under two climate scenarios - Representative Concentration Pathways (RCP4.5 and RCP8.5).

RESULTS

Climate change could substantially increase P. vivax and P. falciparum malaria, under both climate scenarios, but by larger amount under RCP8.5, compared to the baseline. P. falciparum is projected to increase more than P. vivax. The distributions of P. vivax and P. falciparum malaria are expected to increase in most regions regardless of the climate scenarios. A high percentage (>50%) increases are projected in some counties of the northwest, north, northeast, including northern tip of the northeast China, with a clearer spatial change for P. vivax than P. falciparum under both scenarios, highlighting potential changes in the latitudinal extent of the malaria.

CONCLUSION

Our findings suggest that spatial and temporal distribution of P. vivax and P. falciparum malaria in China will change due to future climate change, if there is no policy to mitigate it. These findings are important to guide the malaria elimination goal for China.

Comparative effectiveness of malaria prevention measures: a systematic review and network meta-analysis

Background

Malaria causes significant morbidity and mortality worldwide. There are several preventive measures that are currently employed, including insecticide-treated nets (ITNs, including long-lasting insecticidal nets and insecticidal-treated bed nets), indoor residual spraying (IRS), prophylactic drugs (PD), and untreated nets (UN). However, it is unclear which measure is the most effective for malaria prevention. We therefore undertook a network meta-analysis to compare the efficacy of different preventive measures on incidence of malaria infection.

Methods

A systematic literature review was undertaken across four medical and life sciences databases (PubMed, Cochrane Central, Embase, and Web of Science) from their inception to July 2016 to compare the effectiveness of different preventive measures on malaria incidence. Data from the included studies were analysed for the effectiveness of several measures against no intervention (NI). This was carried out using an automated generalized pairwise modeling (GPM) framework for network meta-analysis to generate mixed treatment effects against a common comparator of no intervention (NI).

Results

There were 30 studies that met the inclusion criteria from 1998–2016. The GPM framework led to a final ranking of effectiveness of measures in the following order from best to worst: PD, ITN, IRS and UN, in comparison with NI. However, only ITN (RR: 0.49, 95% CI: 0.32–0.74) showed precision while other methods [PD (RR: 0.24, 95% CI: 0.004–15.43), IRS (RR: 0.55, 95% CI: 0.20–1.56) and UN (RR: 0.73, 95% CI: 0.28–1.90)] demonstrating considerable uncertainty associated with their point estimates.

Conclusion

Current evidence is strong for the protective effect of ITN interventions in malaria prevention. Even though ITNs were found to be the only preventive measure with statistical support for their effectiveness, the role of other malaria control measures may be important adjuncts in the global drive to eliminate malaria.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2783-y) contains supplementary material, which is available to authorized users.