A comparative analysis of the outcome of malaria case surveillance strategies in Sri Lanka in the prevention of re-establishment phase

Background

Sri Lanka sustained its malaria-free status by implementing, among other interventions, three core case detection strategies namely Passive Case Detection (PCD), Reactive Case Detection (RACD) and Proactive Case Detection (PACD). The outcomes of these strategies were analysed in terms of their effectiveness in detecting malaria infections for the period from 2017 to 2019.

Methods

Comparisons were made between the surveillance methods and between years, based on data obtained from the national malaria database and individual case reports of malaria patients. The number of blood smears examined microscopically was used as the measure of the volume of tests conducted. The yield from each case detection method was calculated as the proportion of blood smears which were positive for malaria. Within RACD and PACD, the yield of sub categories of travel cohorts and spatial cohorts was ascertained for 2019.

Results

A total of 158 malaria cases were reported in 2017–2019. During this period between 666,325 and 725,149 blood smears were examined annually. PCD detected 95.6 %, with a yield of 16.1 cases per 100,000 blood smears examined. RACD and PACD produced a yield of 11.2 and 0.3, respectively. The yield of screening the sub category of travel cohorts was very high for RACD and PACD being 806.5 and 44.9 malaria cases per 100,000 smears, respectively. Despite over half of the blood smears examined being obtained by screening spatial cohorts within RACD and PACD, the yield of both was zero over all three years.

Conclusions

The PCD arm of case surveillance is the most effective and, therefore, has to continue and be further strengthened as the mainstay of malaria surveillance. Focus on travel cohorts within RACD and PACD should be even greater. Screening of spatial cohorts, on a routine basis and solely because people are resident in previously malarious areas, may be wasteful, except in situations where the risk of local transmission is very high, or is imminent. These findings may apply more broadly to most countries in the post-elimination phase.

Case Report: The First Case of Genotypically Confirmed K13 Propeller Mutation in Sri Lanka and Its Implications on the Elimination Status of Malaria

This case report discusses recrudescence of imported Plasmodium falciparum malaria, in the presence of Kelch13 (K13) propeller mutation, in a patient diagnosed and fully treated with artemether-lumefantrine under direct observation in Sri Lanka. This patient presented with a history of 5 days of fever following his arrival from the Democratic Republic of Congo (DRC). He had visited Rwanda 1 week before arrival to Sri Lanka. Treatment was commenced with artemisinin-based combination therapy, artemether-lumefantrine, which is the first-line drug recommended for uncomplicated falciparum malaria. Blood smears were negative for parasites by the third day of treatment. Approximately 2 weeks later, he developed fever again and was diagnosed as having a recrudescence of falciparum malaria. He was treated and responded to the second-line antimalarial dihydroartemisinin-piperaquine. Molecular testing of blood taken from the first infection revealed the presence of amino acid substitutions K189T and R561H within the PfKelch13 gene. R561H mutation is associated with delayed parasite clearance in Southeast Asia. Although seldom reported from DRC, an emergence and clonal expansion of parasites harboring R561H allele has been reported from Rwanda recently; thus, it is likely that this patient may have got the infection from Rwanda. Sri Lanka eliminated malaria in 2016. However, in the backdrop of continuing imported malaria cases, early diagnosis and prompt treatment is essential to prevent the re-establishment of the disease.

Diagnostic challenges and case management of the first imported case of Plasmodium knowlesi in Sri Lanka

Background

Sri Lanka has achieved ‘malaria-free’ status and is now in the phase of prevention of re-introduction of malaria. Imported malaria remains a challenge to resurgence of the disease. The diagnostic challenges encountered and the rapid response initiated to manage a Plasmodium infection, which was later confirmed as Plasmodium knowlesi, the first reported case from Sri Lanka, is discussed.

Case presentation

An army officer who returned from Malaysia in October 2016 was found to be positive for Plasmodium both by microscopy and rapid diagnostic test (RDT) by the Anti Malaria Campaign Sri Lanka (AMC) during his third visit to a health care provider. Microscopy findings were suspicious of P. knowlesi infection as the smears showed parasite stages similar to both Plasmodium malariae and Plasmodium falciparum. Nested PCR at AMC confirmed Plasmodium genus, but not the species. In the absence of species confirmation, the patient was treated as a case of P. falciparum. The presence of P. knowlesi was later confirmed by a semi-nested PCR assay performed at the Environmental Health Institute, National Environmental Agency in Singapore. The parasite strain was also characterized by sequencing the circumsporozoite gene. Extensive case investigation including parasitological and entomological surveillance was carried out.

Conclusions

Plasmodium knowlesi should be suspected in patients returning from countries in the South Asian region where the parasite is prevalent and when blood smear results are inconclusive.

Characterization of imported malaria, the largest threat to sustained malaria elimination from Sri Lanka

Sri Lanka has reached zero indigenous malaria cases in November 2012, two years before its targeted deadline for elimination. Currently, the biggest threat to the elimination efforts are the risk of resurgence of malaria due to imported cases. This paper describes two clusters of imported malaria infections reported in 2013 and 2014, one among a group of Pakistani asylum-seekers resident in Sri Lanka, and the other amongst local fishermen who returned from Sierra Leone. The two clusters studied reveal the potential impact of imported malaria on the risk of reintroducing the disease, as importation is the only source of malaria in the country at present. In the event of a case occurring, detection is a major challenge both amongst individuals returning from malaria endemic countries and the local population, as malaria is fast becoming a “forgotten” disease amongst health care providers. In spite of a very good coverage of diagnostic services (microscopy and rapid diagnostic tests) throughout the country, malaria is being repeatedly overlooked by health care providers even when individuals present with fever and a recent history of travel to a malaria endemic country. Given the high receptivity to malaria in previously endemic areas of the country due to the prevalence of the vector mosquito, such cases pose a significant threat for the reintroduction of malaria to Sri Lanka. The challenges faced by the Anti Malaria Campaign and measures taken to prevent the resurgence of malaria are discussed here.

Usefulness of polymerase chain reaction to supplement field microscopy in a pre-selected population with a high probability of malaria infections

This study determines the use of nested PCR as a diagnostic tool to supplement field microscopy in symptomatic individuals suspected of being positive for malaria, and it explores its role in active case detection to identify asymptomatic parasite carriers. In symptomatic individuals, compared with PCR, microscopy had a sensitivity of 86.6% (95% confidence interval [CI] = 77.8-92.4) and specificity of 100% (95% CI = 96.9-100). During active case detection, two asymptomatic persons were diagnosed as having vivax malaria by polymerase chain reaction (PCR) but not microscopy. Currently, PCR is being carried out in Sri Lanka only for population surveys to estimate the hidden reservoir of malaria. Based on the results of this study and because of cost considerations, pooled PCR will be used in the future to screen samples from clinically suspected foci to increase the proportion of malaria cases detected. This strategy will assist the success of the malaria elimination program in Sri Lanka.