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The rapid elimination of potentially untreatable P. falciparum malaria in South-East Asia is possible, according to a ground-breaking new study published today in The Lancet. The study authors say that setting up community-based malaria clinics for early diagnosis, treatment and monitoring, combined with mass antimalarial drug administration (MDA) to everyone living in ‘hotspot’ areas.

Hand drawn map © Alexander Kumar © 2018 MORU

25 April Bangkok (Thailand) – The rapid elimination of potentially untreatable P. falciparum malaria in South-East Asia is possible, according to a ground-breaking new study published today in The Lancet.

The study authors say that setting up community-based malaria clinics for early diagnosis, treatment and monitoring, combined with mass antimalarial drug administration (MDA) to everyone living in ‘hotspot’ areas – even if they do not show signs of malaria – substantially reduced, often to zero, malaria incidence in remote Myanmar villages.

Combining targeted malaria elimination activities such as these with existing control programmes, study authors say, means that there is a real chance to eliminate drug-resistant P. falciparum malaria, preventing its spread to South Asia and Africa – if authorities and funders act urgently.

“There has been no clear containment strategy so, despite substantial international investment in regional malaria control, drug-resistant malaria now extends across the whole of the Greater Mekong sub-region (GMS). However 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,” said Oxford Prof François Nosten, Director of the Shoklo Malaria Research Unit (SMRU) in Mae Sot, Thailand.

“We are losing a dangerous race to eliminate falciparum malaria before drug resistance spreads beyond South-East Asia and into Africa – and this study shows us how to do it,” said Prof. Nosten.

P. falciparum malaria is the most common of five kinds of malaria parasite that infect humans, and the most likely to cause severe infections that can lead to death. Each year malaria causes close to half a million deaths globally. The spread of artemisinin resistant P. falciparum malaria and subsequent loss of partner antimalarial drugs in the GMS, threatens the global control and elimination of malaria – and could put millions of lives at risk if this drug-resistant malaria spreads to South Asia and Africa.

“This study shows that falciparum malaria could be eliminated rapidly in the GMS, if there was the political and financial support: Provide early detection and treatment of malaria in all malaria affected villages and in hotspots, use mass antimalarial drug administration. But for this to work these drugs need to remain effective, and we are losing them to resistance, so time is running out” said Oxford University Prof Sir Nicholas White, Chairman of the Mahidol Oxford Tropical Medicine Research Unit (MORU) and former chair of the Worldwide Antimalarial Resistance Network (WWARN).

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

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

“This is an important study that shows it is possible to prevent or slow down the spread of drug-resistant malaria by giving anti-malarial treatments to those living in malaria hotspots, alongside support from community-based clinics. The emergence of resistance to the most effective treatment we have 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.

The study identified key elements to successful malaria elimination. After a culturally adapted community engagement phase, they set up more than 1,200 village malaria posts operated by trained villagers to detect, treat and monitor malaria for the nearly 365,000 people living in remote villages in an 18,000 km2 area of eastern Myanmar’s Karen/Kayin State. Then in malaria hotspots – 60 villages where many people carried malaria parasites without being ill – they gave effective antimalarial treatment to everyone living in those villages.

“Careful planning and public engagement to get the support of affected communities is key to ensure success,” explained METF Director Gilles Delmas. “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 to return.”

Version Française de ce reportage, L’élimination du paludisme est possible, à condition d’adopter de nouvelles stratégies

Reference

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. Landier J, Parker DM, Thu AM, Lwin KM, Delmas G, Nosten FH for the Malaria Elimination Task Force Group. The Lancet, Published Online April 24, 2018 http://dx.doi.org/10.1016/ S0140-6736(18)30792-X

The Lancet Comment, Can improving access to care help to eliminate malaria? Azra C. Ghani, MRC Centre for Global Infectiouis Disease Analysis, Dept of Infectious Disease Epidemiology, Imperial College London. Published online April 24, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30910-3

This research was funded with support from The Bill and Melinda Gates Foundation, The Global Fund and Wellcome.

Authors

Jordi Landier, PhD1,2‡, Daniel M. Parker, PhD 1,3‡, Aung Myint Thu, MD1, Khin Maung Lwin, MD1, Gilles Delmas1,4, Prof. François H. Nosten, MD1,4  for the Malaria Elimination Task Force Group.

‡co-first authors

1 Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot,   Thailand.

2 Institut de Recherches pour le Développement, UMR912 SESSTIM (INSERM - IRD - AMU), Marseille, France.

3 Department of Population Health and Disease Prevention, University of California, Irvine, U.S.A.

4 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford.

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