Technical and operational underpinnings of malaria elimination from Sri Lanka

Premaratne, Risintha; Wickremasinghe, Rajitha; Ranaweera, Dewanee; Gunasekera, W. M. Kumudunayana T. de A. W; Hevawitharana, Mihirini; Pieris, Lalanthika; Fernando, Deepika; Mendis, Kamini

doi:10.1186/s12936-019-2886-8

Cited by 53 publications

(57 citation statements)

References 14 publications

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“…Mild adverse reactions were reported during treatment with CQ as given in Table 2, This coupled with the fact that the area where they were resident had a high prevalence of the primary vector of malaria in Sri Lanka, constituted a risk for resumption of transmission. Even the extremely thorough surveillance and case management system for malaria in place in the country at present [1,10] Although in the particular situation described here, MRT was executed and was well tolerated by the individuals with no occurrence of serious adverse events, the procedure faced many operational and technical challenges. Tools to screen for G6PD activity prior to treatment with PQ, the only registered anti-relapse medicine today, were not optimal.…”

Section: Resultsmentioning

confidence: 99%

“…These were the only tests that were available and feasible to use in this situation, and neither were quantitative. Therefore, using the approach of an abundance of caution, almost a quarter of the group of individuals had to be excluded from PQ treatment on the grounds that they tested positive for Surveillance, both parasitological and entomological is one of the key strategies used by the AMC to maintain zero transmission since the elimination of malaria in 2012 [1]. With 378 imported malaria cases being diagnosed between 2013-2019, the country remains vulnerable to the re-introduction of malaria.…”

Section: Resultsmentioning

confidence: 99%

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Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Marasinghe

Karunasena

Senaratne

et al. 2020

Preprint

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Background Following malaria elimination, Sri Lanka was free from indigenous transmission for six consecutive years, until the first introduced case was reported in December 2018. The source of transmission (index case) was a member of a group of 32 migrant workers from India and the location of transmission was their residence reporting a high prevalence of the primary vector for malaria. Despite extensive vector control the situation was highly susceptible to onward transmission if another of the group developed malaria. Therefore, Mass Radical Treatment (MRT) of the group of workers for Plasmodium vivax malaria was undertaken to mitigate this risk. Method The workers were screened for malaria by microscopy and RDT, their haemoglobin level assessed, and tested for Glucose 6 phosphate dehydrogenase deficiency (G6PD) using the Care Start RDT and Brewers test prior to treatment with chloroquine (CQ) 25mg/kg body weight (over three days) and primaquine (PQ) (0.25mg/kg/day bodyweight for 14 days) following informed consent. All were monitored for adverse events. Results None of the foreign workers were parasitaemic at baseline screening and their haemaglobin levels ranged from 9.7 – 14.7 g/dl. All 31 individuals (excluding the index case treated previously) were treated with the recommended dose of CQ. The G6PD test results were inconclusive in 45% of the RDT results and were discrepant between the two tests in 31% of the remaining test events. Seven workers who tested G6PD deficient in either test were excluded from PQ and the rest 24 received PQ. No serious adverse events occurred. Conclusions Mass treatment may be an option in prevention of reintroduction settings for groups of migrants who are likely to be carrying latent malaria infections, and resident in areas of high receptivity. However, in the case of P.vivax and P.ovale , a more reliable and affordable point-of-care test for G6PD activity would be required. Most countries which are eliminating malaria now are in the tropical zone and face considerable and similar risks of malaria re-introduction due to massive labour migration between them and neighbouring countries. Regional elimination of malaria should be the focus of global strategy if malaria elimination from countries is to be worthwhile and sustainable.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Marasinghe

Karunasena

Senaratne

et al. 2020

Preprint

Self Cite

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“…A signi cant feature in the prevention of reintroduction (POR) phase of malaria in Sri Lanka is the high receptivity and vulnerability in parts of the country owing to the persistence of malaria vectors and the high rate of importation of malaria cases [1]. Even though an effective surveillance system is in operation, these conditions impose a signi cant risk of malaria re-introduction post-elimination [2].…”

Section: Introductionmentioning

confidence: 99%

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Marasinghe

Karunasena

Senaratne

et al. 2020

Preprint

Self Cite

View full text Add to dashboard Cite

Background Following malaria elimination, Sri Lanka was free from indigenous transmission for six consecutive years, until the first introduced case was reported in December 2018. The source of transmission (index case) was a member of a group of 32 migrant workers from India and the location of transmission was their residence reporting a high prevalence of the primary vector for malaria. Despite extensive vector control the situation was highly susceptible to onward transmission if another of the group developed malaria. Therefore, Mass Radical Treatment (MRT) of the group of workers for Plasmodium vivax malaria was undertaken to mitigate this risk. Method The workers were screened for malaria by microscopy and RDT, their haemoglobin level assessed, and tested for Glucose 6 phosphate dehydrogenase deficiency (G6PD) using the Care Start RDT and Brewers test prior to treatment with chloroquine (CQ) 25mg/kg body weight (over three days) and primaquine (PQ) (0.25mg/kg/day bodyweight for 14 days) following informed consent. All were monitored for adverse events. Results None of the foreign workers were parasitaemic at baseline screening and their haemoglobin levels ranged from 9.7 – 14.7 g/dl. All 31 individuals (excluding the index case treated previously) were treated with the recommended dose of CQ. The G6PD test results were inconclusive in 45% of the RDT results and were discrepant between the two tests in 31% of the remaining test events. Seven workers who tested G6PD deficient in either test were excluded from PQ and the rest, 24 workers, received PQ. No serious adverse events occurred. Conclusions Mass treatment may be an option in prevention of reintroduction settings for groups of migrants who are likely to be carrying latent malaria infections, and resident in areas of high receptivity. However, in the case of Plasmodium vivax and Plasmodium ovale, a more reliable and affordable point-of-care test for G6PD activity would be required. Most countries which are eliminating malaria now are in the tropical zone and face considerable and similar risks of malaria re-introduction due to massive labour migration between them and neighbouring countries. Regional elimination of malaria should be the focus of global strategy if malaria elimination from countries is to be worthwhile and sustainable.

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“…Most of the countries that have already eliminated have lower receptivity, and they maintain elimination through excellent clinical surveillance, focal case investigation, and in some cases entomological surveillance and response (6). In contrast, many of the remaining malaria-endemic countries have much higher intrinsic transmission potential and are surrounded by other countries facing the same issues, making their path toward elimination technically, operationally, and financially challenging.…”

Section: Introductionmentioning

confidence: 99%

Effective strategies for preventing reestablishment of malaria in areas with recent elimination and high transmission potential

Gerardin

Bever

Bridenbecker

et al. 2019

Preprint

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Maintaining zero transmission after malaria elimination will be a challenging task for many countries where malaria is still endemic. When local transmission potential is high, and importation of malaria infections continues from neighboring areas with ongoing transmission, malaria programs must develop robust surveillance and outbreak response systems. However, the requirements for such systems remain unclear. Using an agent-based, spatial microsimulation model of two areas in southern Zambia, where elimination efforts are currently underway, we compare the ability of various routine and reactive intervention packages to maintain near-zero prevalence in the face of continued importation. We find that in formerly moderate-transmission areas, high treatment rate of symptomatic malaria is sufficient to prevent reestablishment of malaria. Routine redistributions of insecticide-treated nets and reactive case detection with antimalarial drugs cannot completely compensate for inadequate case management. In formerly high-transmission areas, excellent case management and maintenance of good bednet coverage are both required to prevent resurgence, and outbreak response with antimalarial drugs or additional vector control is also necessary. These results begin to describe the essential criteria for operations that successfully prevent reestablishment of malaria post-elimination and highlight the need for both long-term, sustainable excellence in primary care and comprehensive surveillance that feeds into rapid and flexible outbreak response. Author SummaryThe global community is working toward malaria elimination, but some areas will eliminate before others. Eliminated areas will need to develop intervention programs capable of preventing imported infections from leading to reestablishment, a particular challenge when transmission was previously very high. Past experience has shown that stopping elimination interventions leads to massive resurgence, but it is unclear which interventions must be continued, which can be stopped to conserve resources, and what new interventions should be deployed. Using a simulation model built to capture malaria transmission and intervention history of two areas that recently made enormous progress toward elimination, we tested how well different intervention programs were able to prevent reestablishment of malaria. We found that treating as many symptomatic cases as possible was the single most important intervention to implement. In some contexts, this intervention alone was sufficient to prevent reestablishment. Other areas with historically higher transmission required maintaining vector control to contain mosquito populations. Localized outbreak response with antimalarial drugs or additional vector control was also necessary and predicted to be a highly efficient use of resources. These findings provide quantitative guidance for policy-makers considering how to stratify eliminated areas and plan new operational modes for the post-elimination era.

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Technical and operational underpinnings of malaria elimination from Sri Lanka

Cited by 53 publications

References 14 publications

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Effective strategies for preventing reestablishment of malaria in areas with recent elimination and high transmission potential

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