Malaria elimination in the Greater Mekong sub-region

Multidrug resistant P. falciparum malaria is now established in parts of Thailand, Laos and Cambodia, causing high treatment failure rates for artemisinin combination therapies, the main falciparum malaria medicines. A further spread from Myanmar to India then sub-Saharan Africa would be a global public health disaster. TME seeks the best ways to eliminate drug-resistant malaria, using both technical solutions and novel ways that engage entire communities.

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Artemisinin resistance has emerged in Cambodia, eastern Myanmar, southern Lao PDR (Laos) and Vietnam. This severely compromises falciparum malaria control efforts in the region, which depends on the continued efficacy of artemisinin combination therapies (ACT). Artemisinin resistance has the potential to spread throughout the malaria endemic regions of the world. The severity of this threat has been recognized and containment efforts have started or are under development. Addressing the problem involves elimination of falciparum malaria in areas of artemisinin resistance. If parasite populations in these foci are allowed to remain, evolving artemisinin resistance related to continuing drug pressure will spread.

In the last decade, P. falciparum transmission in the Greater Mekong Subregion has decreased substantially. A reversal of the current progress in malaria control would have tragic consequences. We explore the use of presumptive antimalarial treatment with  Dihydroartemisinin-piperaquine (DHA-PIP) of entire village populations. This intervention will target communities with significant levels of subclinical parasite infections and transmission.

DHA-PIP is a highly efficacious and inexpensive ACT, which is well tolerated by all age groups when used to treat uncomplicated multidrug resistant falciparum malaria in South East Asia. Monthly DHA-PIP  treatments have proved highly effective and well tolerated. When used as part of a TME strategy, the addition of a gametocytocidal drug such as primaquine (PQ), will contribute a strong transmission blocking activity by killing gametocytes. PQ, the only currently licensed 8-aminoquinoline, is safe and effective when used at a dose of 0.25 mg base/kg irrespective of G6PD status.