Exploring the role of socioeconomic factors in the development and spread of anti-malarial drug resistance: a qualitative study

Socioeconomic, Demographic, and Environmental Factors May Inform Malaria Intervention Prioritization in Urban Nigeria

Urban population growth in Nigeria may exceed the availability of affordable housing and basic services, resulting in living conditions conducive to vector breeding and heterogeneous malaria transmission. Understanding the link between community-level factors and urban malaria transmission informs targeted interventions. We analyzed Demographic and Health Survey Program cluster-level data, alongside geospatial covariates, to describe variations in malaria prevalence in children under 5 years of age. Univariate and multivariable models explored the relationship between malaria test positivity rates at the cluster level and community-level factors. Generally, malaria test positivity rates in urban areas are low and declining. The factors that best predicted malaria test positivity rates within a multivariable model were post-primary education, wealth quintiles, population density, access to improved housing, child fever treatment-seeking, precipitation, and enhanced vegetation index. Malaria transmission in urban areas will likely be reduced by addressing socioeconomic and environmental factors that promote exposure to disease vectors. Enhanced regional surveillance systems in Nigeria can provide detailed data to further refine our understanding of these factors in relation to malaria transmission.

Factors Contributing to the Pre-Elimination of Malaria from Hainan Island, China, 1986-2009

Malaria was endemic in Hainan Island, China, for a lengthy period before its elimination. Here, we aim to gain a better understanding of malaria elimination by assessing and quantifying the relative effects of longitudinal changes in specific antimalarial interventions, socioeconomic development approaches, and malaria vectors on malaria prevalence in Hainan during the 1986-2009 pre-elimination period. Annual data were collected on the incidence of malaria, the number of residents protected by drugs (RPD), the number of residents protected by vector control, the presence of Anopheles minimus and Anopheles dirus, the annual per capita income of rural residents, major cash crop (rubber plantation) areas, the literacy rate of adult rural residents, and the rate of reinforced concrete house construction in rural areas. Backward stepwise multiple linear regression models were developed to identify the factors associated with the annual malaria incidence (AMI). The AMI declined from 20.3 to 0.8 per 10,000 population from 1986 to 2009; this decrease was significantly associated with an increase in the number of RPD and improved literacy rate among rural adults. The results of this study implied that the sustained distribution of antimalarial drugs and increase in education levels in risk areas significantly impacted the reduction and elimination of malaria infection in Hainan. We suggest that these findings could be applicable to malaria-endemic areas in Southeast Asia with similar natural and socioeconomic environments to Hainan and where malaria incidence has decreased to a low level.

The impact of anti-malarial markets on artemisinin resistance: perspectives from Burkina Faso

BACKGROUND

Widespread artemisinin resistance in Africa could be catastrophic when drawing parallels with the failure of chloroquine in the 1970s and 1980s. This article explores the role of anti-malarial market characteristics in the emergence and spread of arteminisin resistance in African countries, drawing on perspectives from Burkina Faso.

METHODS

Data were collected through in-depth interviews and focus group discussions. A representative sample of national policy makers, regulators, public and private sector wholesalers, retailers, clinicians, nurses, and community members were purposively sampled. Additional information was also sought via review of policy publications and grey literature on anti-malarial policies and deployment practices in Burkina Faso.

RESULTS

Thirty seven in-depth interviews and 6 focus group discussions were conducted. The study reveals that the current operational mode of anti-malarial drug markets in Burkina Faso promotes arteminisin resistance emergence and spread. The factors are mainly related to the artemisinin-based combination therapy (ACT) supply chain, to ACT quality, ACT prescription monitoring and to ACT access and misuse by patients.

CONCLUSION

Study findings highlight the urgent requirement to reform current characteristics of the anti-malarial drug market in order to delay the emergence and spread of artemisinin resistance in Burkina Faso. Four recommendations for public policy emerged during data analysis: (1) Address the suboptimal prescription of anti-malarial drugs, (2) Apply laws that prohibit the sale of anti-malarials without prescription, (3) Restrict the availability of street drugs, (4) Sensitize the population on the value of compliance regarding correct acquisition and intake of anti-malarials. Funding systems for anti-malarial drugs in terms of availability and accessibility must also be stabilized.

Low Complexity of Infection Is Associated With Molecular Persistence of Plasmodium falciparum in Kenya and Tanzania

Background

Plasmodium falciparum resistance to artemisinin-based combination therapies (ACTs) is a threat to malaria elimination. ACT-resistance in Asia raises concerns for emergence of resistance in Africa. While most data show high efficacy of ACT regimens in Africa, there have been reports describing declining efficacy, as measured by both clinical failure and prolonged parasite clearance times.

Methods

Three hundred children aged 2-10 years with uncomplicated P. falciparum infection were enrolled in Kenya and Tanzania after receiving treatment with artemether-lumefantrine. Blood samples were taken at 0, 24, 48, and 72 h, and weekly thereafter until 28 days post-treatment. Parasite and host genetics were assessed, as well as clinical, behavioral, and environmental characteristics, and host anti-malarial serologic response.

Results

While there was a broad range of clearance rates at both sites, 85% and 96% of Kenyan and Tanzanian samples, respectively, were qPCR-positive but microscopy-negative at 72 h post-treatment. A greater complexity of infection (COI) was negatively associated with qPCR-detectable parasitemia at 72 h (OR: 0.70, 95% CI: 0.53-0.94), and a greater baseline parasitemia was marginally associated with qPCR-detectable parasitemia (1,000 parasites/uL change, OR: 1.02, 95% CI: 1.01-1.03). Demographic, serological, and host genotyping characteristics showed no association with qPCR-detectable parasitemia at 72 h. Parasite haplotype-specific clearance slopes were grouped around the mean with no association detected between specific haplotypes and slower clearance rates.

Conclusions

Identifying risk factors for slow clearing P. falciparum infections, such as COI, are essential for ongoing surveillance of ACT treatment failure in Kenya, Tanzania, and more broadly in sub-Saharan Africa.

Rural-Urban Differentials in Access to Behaviour Change Communication and Use of Long-Lasting Insecticide-Treated Nets and Artemisinin-Based Combination Therapy in Southeast Nigeria

BACKGROUND

As Malaria continues to take a heavy toll on the life and economy of Nigerians, The National Malaria Elimination Programme uses behaviour change communication (BCC) to promote the use of Long-Lasting Insecticide-treated Nets (LLIN) and Artemisinin-based Combination Therapy (ACT) to combat malaria. This study examined the impact of BCC on the use of LLIN and ACT in Southeast Nigeria.

METHODS

A structured questionnaire was used to gather data from 480 respondents in urban and rural communities across five states. Analysis of data was done using percentages, chi-square and logistic regression.

RESULTS

Findings showed weak effect of BCC on LLIN and ACT use despite achieving high (93.75%) exposure. Only 45.1% and 45.7% of the respondents used LLIN and ACT respectively. Urban residents were found to sleep under LLINs and use ACTs more than rural dwellers. Regression results showed that newspapers (OR=1.341) and the Internet (OR=3.216) increased the odds of LLIN use in the rural areas and magazines (OR=1.837) in the urban areas. Television (OR=2.375; P=0.002) and the Internet (OR=6.063; P=0.001) increased the odds of ACT use in the urban areas. Education was found to be a positive predictor of LLIN use in the rural (OR=4.645; P=0.011) and urban areas (OR=6.102) as well as ACT use in the rural (OR=7.268; p=0.002) and urban areas (0R=6.145; P=0.009).

CONCLUSION

Access to behaviour change communication though very high has not achieved the desired behaviour change. The National Malaria Elimination Programme should produce appropriate messages to address barriers to LLIN and ACT use.

Antimalarial Drug Resistance and Implications for the WHO Global Technical Strategy

PURPOSE OF REVIEW

Five years have passed since the World Health Organization released its Global Technical Strategy for Malaria (GTS). In that time, progress against malaria has plateaued. This review focuses on the implications of antimalarial drug resistance for the GTS and how interim progress in parasite genomics and antimalarial pharmacology offer a bulwark against it.

RECENT FINDINGS

For the first time, drug resistance-conferring genes have been identified and validated before their global expansion in malaria parasite populations. More efficient methods for their detection and elaboration have been developed, although low-density infections and polyclonality remain a nuisance to be solved. Clinical trials of alternative regimens for multidrug-resistant malaria have delivered promising results. New agents continue down the development pipeline, while a nascent infrastructure in sub-Saharan Africa for conducting phase I trials and trials of transmission-blocking agents has come to fruition after years of preparation.

SUMMARY

These and other developments can help inform the GTS as the world looks ahead to the next two decades of its implementation. To remain ahead of the threat that drug resistance poses, wider application of genomic-based surveillance and optimization of existing and forthcoming antimalarial drugs are essential.

An economic analysis of malaria elimination program in Nepal

BACKGROUND

Governments have committed to eliminate malaria. But a decline in government investment in malaria interventions, particularly in developing countries such as Nepal, reveals a limited emphasis on malaria elimination that may be due to lack of strong evidence on benefits of the investment. This paper empirically analyses curative and preventive costs and benefits of Nepal's malaria elimination program from the perspectives of both service providers in the public sector and people who are at risk.

METHODS

Cost benefit analysis of both curative and preventive interventions for malaria elimination was conducted using case and non-case household survey data. Secondary data were obtained from government sources. Ingredient approach and step-down methods were used to estimate costs of malaria elimination interventions, and willingness to pay (WTP) method and case averted approach to estimate benefits.

RESULTS

Curative intervention of malaria elimination program is economically viable in Nepal with a net present value (NPV) of USD 23 million, benefit cost ratio (BCR) of 1.58 and internal rate of return of 63%. Malaria preventive intervention is highly beneficial with NPV of USD 435 million and BCR of 2.13. An annual investment of USD 36.59 million is required to continue the current pattern of malaria reduction that can generate societal benefits of USD 92.81 million. From this investment, the government can save USD 132 million by the end of 2025. The maximum WTP of case households for the intervention is USD 57 per household which is 63% higher than that of non-case households.

CONCLUSION

Malaria elimination program in Nepal is economically viable and investment worthy. As the preventive intervention generates much higher net benefits than the curative intervention, the government should emphasize on preventive intervention while continuing the curative interventions.

Clinical and epidemiological characterization of severe Plasmodium vivax malaria in Gujarat, India

The mounting evidence supporting the capacity of Plasmodium vivax to cause severe disease has prompted the need for a better characterization of the resulting clinical complications. India is making progress with reducing malaria, but epidemics of severe vivax malaria in Gujarat, one of the main contributors to the vivax malaria burden in the country, have been reported recently and may be the result of a decrease in transmission and immune development. Over a period of one year, we enrolled severe malaria patients admitted at the Civil Hospital in Ahmedabad, the largest city in Gujarat, to investigate the morbidity of severe vivax malaria compared to severe falciparum malaria. Patients were submitted to standard thorough clinical and laboratory investigations and only PCR-confirmed infections were selected for the present study. Severevivax malaria (30 patients) was more frequent than severe falciparum malaria (8 patients) in our setting, and it predominantly affected adults (median age 32 years, interquartile range 22.5 years). This suggests a potential age shift in anti-malarial immunity, likely to result from the recent decrease in transmission across India. The clinical presentation of severe vivax patients was in line with previous reports, with jaundice as the most common complication. Our findings further support the need for epidemiological studies combining clinical characterization of severe vivax malaria and serological evaluation of exposure markers to monitor the impact of elimination programmes.

Community-informed research on malaria in pregnancy in Monrovia, Liberia: a grounded theory study

BACKGROUND

Liberia is a West African country that needs substantial investment to strengthen its National Malaria Control Programme (NMCP), which was disrupted during the 2014-2016 Ebola epidemic. As elsewhere, Liberian pregnant women are especially vulnerable to malaria. Understanding prevention and treatment-seeking behaviours among the population is crucial to strategize context-specific and women-centred actions, including locally-led malaria research, to improve women's demand, access and use of NMCP strategies against malaria in pregnancy.

METHODS

In 2016, after the Ebola crisis, a qualitative inquiry was conducted in Monrovia to explore populations' insights on the aetiology, prevention and therapeutics of malaria, as well as the community and health workers' perceptions on the utility of malaria research for pregnant women. In-depth interviews and focus group discussions were conducted among pregnant women, traditional community representatives and hospital staff (n = 38), using a feminist interpretation of grounded theory.

RESULTS

The narratives indicate that some Liberians believed in elements other than mosquito bites as causes of malaria; many had a low malaria risk perception and disliked current effective prevention methods, such as insecticide-treated nets; and some would resort to traditional medicine and spiritual care to cure malaria. Access to clinic-based malaria care for pregnant women was reportedly hindered by lack of financial means, by unofficial user fees requested by healthcare workers, and by male partners' preference for traditional medicine. The participants suggested that malaria research in Liberia could help to design evidence-based education to change current malaria prevention, diagnostic and treatment-seeking attitudes, and to develop more acceptable prevention technologies.

CONCLUSION

Poverty, insufficient education on malaria, corruption, and poor trust in healthcare establishment are structural factors that may play a greater role than local traditional beliefs in deterring Liberians from seeking, accessing and using government-endorsed malaria control strategies. To increase access to and uptake of preventive and biomedical care by pregnant women, future malaria research must be informed by people's expressed needs and constructed meanings and values on health, ill health and healthcare.

Micro-epidemiology of mixed-species malaria infections in a rural population living in the Colombian Amazon region

Malaria outbreaks have been reported in recent years in the Colombian Amazon region, malaria has been re-emerging in areas where it was previously controlled. Information from malaria transmission networks and knowledge about the population characteristics influencing the dispersal of parasite species is limited. This study aimed to determine the distribution patterns of Plasmodium vivax, P. malariae and P. falciparum single and mixed infections, as well as the significant socio-spatial groupings relating to the appearance of such infections. An active search in 57 localities resulted in 2,106 symptomatic patients being enrolled. Parasitaemia levels were assessed by optical microscopy, and parasites were detected by PCR. The association between mixed infections (in 43.2% of the population) and socio-spatial factors was modelled using logistic regression and multiple correspondence analyses. P. vivax occurred most frequently (71.0%), followed by P. malariae (43.2%), in all localities. The results suggest that a parasite density-dependent regulation model (with fever playing a central role) was appropriate for modelling the frequency of mixed species infections in this population. This study highlights the under-reporting of Plasmodium spp. mixed infections in the malaria-endemic area of the Colombian Amazon region and the association between causative and environmental factors in such areas.

The use and preference of artemether as a first-choice treatment for malaria: results from a cross-sectional survey in the Bata district, Equatorial Guinea

BACKGROUND

Malaria is endemic in Equatorial Guinea with stable transmission, and it remains a major cause of morbidity and mortality in children under 5 years of age. Adherence to artemisinin-based combination therapy (ACT) as a first-line treatment for uncomplicated malaria is critical to malaria control. Six years after the introduction of artesunate-amodiaquine (AS/AQ) therapy in Equatorial Guinea, adherence to the first-line treatment seems to be low in the Bata district. The factors associated with the choice of malaria treatment have not been studied previously in this area; therefore, this study aimed to analyse the preference and use of artemether as malaria treatment and its related factors in the Bata district of Equatorial Guinea.

METHODS

In 2013, a cross-sectional study was conducted in the Bata district, which involved 428 households. Bivariate and multivariate statistical analyses were conducted to determine the relevance of socio-economic, geographical, and behavioural factors that played a role in the preference and use of artemether as malaria treatment.

RESULTS

Artemether was considered the best treatment for malaria by 110 caregivers (26%), and was the antimalarial most administrated in the Bata district. It was prescribed to 117 children (27.34%); while, only 6.78% were administered AS/AQ. Caregivers living ≤ 3 km from the nearest health facility were almost two times more likely to consider artemether as the best treatment than those living farther away (95% CI 0.31-0.86). Caregivers with at least a secondary school education were 2.7 times more likely to consider artemether as the best treatment than those less educated. Children whose caregivers considered artemether the best treatment against malaria were five times more likely to be treated with artemether than children with caregivers who did not consider it the best (OR 5.07, 95% CI 2.93-8.78). In contrast, children that reported weakness as a symptom were less likely to be treated with artemether than those with other symptoms (OR 0.47, 95% CI 0.28-0.78).

CONCLUSION

Caregivers, public and private health staff, and drug sellers need to understand the importance of using ACT to treat uncomplicated malaria and the dangers of using artemisinin monotherapy.

Evolutionary ARMS Race: Antimalarial Resistance Molecular Surveillance

Molecular surveillance of antimalarial drug resistance markers has become an important part of resistance detection and containment. In the current climate of multidrug resistance, including resistance to the global front-line drug artemisinin, there is a consensus to upscale molecular surveillance. The most salient limitation to current surveillance efforts is that skill and infrastructure requirements preclude many regions. This includes sub-Saharan Africa, where Plasmodium falciparum is responsible for most of the global malaria disease burden. New molecular and data technologies have emerged with an emphasis on accessibility. These may allow surveillance to be conducted in broad settings where it is most needed, including at the primary healthcare level in endemic countries, and extending to the village health worker.