MALARIA: Reducing Plasmodium falciparum Malaria Transmission in Africa: A Model-Based Evaluation of Intervention Strategies

Background. Half the world’s population is at risk of malaria, and every year nearly one million people—mainly children living in sub-Saharan Africa—die from this mosquito-borne parasitic disease. Most malarial deaths are caused by Plasmodium falciparum, which is transmitted to people by mainly night-biting Anopheles mosquitoes. When infected mosquitoes feed on people, they inject sporozoites, a parasitic form that replicates inside human liver cells. After
a few days, the liver cells release ‘‘merozoites,’’ which invade red blood cells where they replicate rapidly before bursting out and infecting more red blood cells. This increase in the parasitic burden causes malaria’s characteristic fever.
Infected red blood cells also release ‘‘gametocytes,’’ which infect mosquitoes when they take a blood meal. In the mosquito, the gametocytes multiply and develop into sporozoites, thus completing the parasite’s life cycle.
Malaria can be prevented by spraying the insides of houses (where most anopheles species feed and rest) with insecticides (indoor residual spraying, IRS) and by sleeping under bed nets that have been treated with long-lasting
insecticides (long-lasting insecticide nets, LLINs). Mass screening and treatment (MSAT) with effective antimalarial drugs can also reduce malaria transmission.
Why Was This Study Done? Early attempts to eradicate malaria (reduce its global incidence to zero) in the 1950s reduced the incidence of malaria to zero in some countries (malaria elimination) and greatly reduced malarial illnesses and
deaths in others (malaria control). However, this eradication program was aborted in the 1970s in part because of emerging drug and insecticide resistance. Recently, the advent of artemisinin-based combination therapies and new insecticides and the prospect of a malaria vaccine have renewed interest in
controlling, eliminating, and ultimately eradicating malaria.
Consequently, in September 2008, the Roll Back Malaria Partnership launched the Global Malaria Action Plan, which aims to reduce malaria deaths to near zero by 2015. But are the currently available tools for reducing malaria transmission
sufficient to control and eliminate malaria in Africa, the continent where most malaria deaths occur? In this study, the researchers use a new mathematical model of P. falciparum transmission to investigate this question.
What Did the Researchers Do and Find? The researchers’ P. falciparum transmission model consists of ‘‘compartments’’ through which individuals pass as they become infected with parasites, develop immunity, become
infectious to mosquitoes, and so on. The researchers used published data about parasite prevalence (the proportion of the population infected with parasites) and about relevant aspects of mosquito, parasite, and human biology, to
estimate the chances of an individual moving between compartments. Finally, they used the model to explore the impact over 25 years of increased coverage of LLINs, IRS, and MSAT, and of a future vaccine on malaria transmission in six
representative African settings. In a low-transmission setting, 80% coverage with LLINs reduced the parasite prevalence to below 1% in all age groups. In two moderate-transmission settings, LLIN scale-up alone failed to reach this target but the addition of IRS and MSAT drove the parasite prevalence below 1%. However, this combination of interventions did not control malaria in a moderate-transmission setting in which a mosquito species that bites and rests outside houses contributes to malaria transmission. Finally, in two hightransmission
settings, parasite prevalence could be driven below 1% only by setting unrealistic coverage targets for existing interventions.
What Do These Findings Mean? This new mathematical model greatly simplifies the complex dynamics of malaria transmission and includes several assumptions about which there is considerable uncertainty. The findings of this study are not, therefore, firm predictions of the future of malaria control in specific settings. Nevertheless, they suggest that it should be possible to make large reductions in malaria transmission and the associated disease burden in Africa over the next 25 years using currently available tools. Specifically, in regions where transmission is low or moderate and mosquitoes mainly feed indoors, it should be possible to reduce parasite prevalence to less than 1% provided a sustained intervention program is achieved. Importantly, however, these findings suggest that in regions where malaria transmission is high or where mosquitoes rest and bite outside houses, new approaches will be needed to control and eliminate malaria.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000324