Meteorological, environmental remote sensing and neural network analysis of the epidemiology of malaria transmission in Thailand

In many malarious regions malaria transmission roughly coincides with rainy seasons, which provide for more abundant larval habitats. In addition to precipitation, other meteorological and environmental factors may also influence malaria transmission. These factors can be remotely sensed using earth observing environmental satellites and estimated with seasonal climate forecasts. The use of remote sensing usage as an early warning tool for malaria epidemics have been broadly studied in recent years, especially for Africa, where the majority of the world’s malaria occurs. Although the Greater Mekong Subregion (GMS), which includes Thailand and the surrounding countries, is an epicenter of multidrug resistant falciparum malaria, the meteorological and environmental factors affecting malaria transmissions in the GMS have not been examined in detail. In this study, the parasitological data used consisted of the monthly malaria epidemiology data at the provincial level compiled by the Thai Ministry of Public Health. Precipitation, temperature, relative humidity, and vegetation index obtained from both climate time series and satellite measurements were used as independent variables to model malaria. We used neural network methods, an artificial-intelligence technique, to model the dependency of malaria transmission on these variables. The average training accuracy of the neural network analysis for three provinces (Kanchanaburi, Mae Hong Son, and Tak) which are among the provinces most endemic for malaria, is 72.8% and the average testing accuracy is 62.9% based on the 1994-1999 data. A more complex neural network architecture resulted in higher training accuracy but also lower testing accuracy. Taking into account of the uncertainty regarding reported malaria cases, we divided the malaria cases into bands (classes) to compute training accuracy. Using the same neural network architecture on the 19 most endemic provinces for years 1994 to 2000, the mean training accuracy weighted by provincial malaria cases was 73%. Prediction of malaria cases for 2001 using neural networks trained for 1994-2000 gave a weighted accuracy of 53%. Because there was a significant decrease (31%) in the number of malaria cases in the 19 provinces from 2000 to 2001, the networks overestimated malaria transmissions. The decrease in transmission was not due to climatic or environmental changes. Thailand is a country with long borders. Migrant populations from the neighboring countries enlarge the human malaria reservoir because these populations have more limited access to health care. This issue also confounds the complexity of modeling malaria based on meteorological and environmental variables alone. In spite of the relatively low resolution of the data and the impact of migrant populations, we have uncovered a reasonably clear dependency of malaria on meteorological and environmental remote sensing variables. When other contextual determinants do not vary significantly, using neural network analysis along with remote sensing variables to predict malaria endemicity should be feasible

Natural infection of Plasmodium falciparum induces inhibitory antibodies against gametocyte development in human hosts.

SUMMARY: We identified naturally induced antibodies from malaria patients in Thailand and clarified the effect of the antibodies on gametocyte development. Fifty-nine percent of the Plasmodium falciparum-infected blood samples (17 of 29) fed to female Anopheles mosquitoes showed no oocyst infection. Seventeen percent of the samples (5 of 29) distorted the morphology and hampered the maturity of the gametocytes. A possible mechanism for the gametocyte inhibitory activity was shown by the binding of the plasma antibodies to live, immature, intraerythrocytic gametocytes during the incubation period. One hundred fifty-seven proteins specific to different gametocyte stages were explored to find the targets of the antisera that bound to the live gametocytes. However, no additional gametocyte transmission-blocking vaccine candidate was detected. Therefore, the development of alternative transmission-blocking vaccines in high-transmission areas should focus on the identification of more gametocyte antigens-inducing inhibitory antibodies that reduce gametocytemia

Risk factors, clinical features and treatment of human infection with Plasmodium knowlesi and other Plasmodium species in Sabah, Malaysia

The simian parasite Plasmodium knowlesi is an emergent public health threat in southeast Asia,  with human infections now increasingly reported where its macaque hosts and An. Leucosphyrus  group vector are present. In Malaysia, P. knowlesi is now the most common cause of human  malaria, and has been demonstrated to cause severe and fatal disease. This thesis aimed to provide further understanding of the epidemiology, clinical and laboratory features, and  treatment of P.knowlesi malaria in both children and adults, with studies conducted in an area of  northwest Sabah, Malaysia. Firstly, the major epidemiological study in this thesis was a case-control analysis of factors  associated with acquiring symptomatic P. knowlesi infection. Key findings demonstrated the  highest risk in farmers, specific activities such as plantation work and clearing vegetation,  sleeping outside, travel, and other environmental and household factors, particularly at the  forest-edge, although peri-domestic transmission was also evident. Intrinsic factors such as G6PD  deficiency in humans were shown to have a protective benefit, in addition to conventional  malaria prevention activities such as insecticide spraying of household walls. The presence of  spatio-temporal case-clustering through analysis of P. knowlesi dhfr sequences was demonstrated, however was not found to be related to drug selection pressure from human-to-human transmission. Secondly, a large prospective study in three district hospitals detailed the clinical and laboratory features in children and adults with knowlesi malaria, highlighting the significant morbidity due  to anaemia and acute kidney injury in children, despite an absence of severe complications in this  group. A lower pyrogenic threshold was seen with lower parasitaemia compared to other  Plasmodium species overall. The risk of severe disease was 6.4% in adults, with independent  predictors of severe disease including age ≥45 years and parasitaemia >15,000/μL. Finally, two major randomised controlled trials for the treatment of uncomplicated knowlesi and  vivax malaria in Malaysia were conducted comparing an ACT, artesunate-mefloquine, against  chloroquine in adults and children. Faster parasite and fever clearance, and decreased anaemia  risk at day 28 was seen in the artesunate-mefloquine arm in both studies. There were no treatment failures in the P. knowlesi study. High-grade P. vivax chloroquine resistance was  demonstrated in the P. vivax study, with a 61% risk of recurrence at day 28. These studies support the use of ACT as the first-line blood stage treatment for malaria due to all Plasmodium species in this co-endemic area, which is now reflected in national Malaysian treatment  guidelines

Plasmodium knowlesi Malaria in Humans and Macaques, Thailand

This parasite may be transmitted from macaques to humans

Genetic Diversity and Lack of Artemisinin Selection Signature on the Plasmodium falciparum ATP6 in the Greater Mekong Subregion

The recent detection of clinical Artemisinin (ART) resistance manifested as delayed parasite clearance in the Cambodia-Thailand border area raises a serious concern. The mechanism of ART resistance is not clear; but the P. falciparum sarco/endoplasmic reticulum Ca2+-ATPase (PfSERCA or PfATP6) has been speculated to be the target of ARTs and thus a potential marker for ART resistance. Here we amplified and sequenced pfatp6 gene (~3.6 Kb) in 213 samples collected after 2005 from the Greater Mekong Subregion, where ART drugs have been used extensively in the past. A total of 24 single nucleotide polymorphisms (SNPs), including 8 newly found in this study and 13 nonsynonymous, were identified. However, these mutations were either uncommon or also present in other geographical regions with limited ART use. None of the mutations were suggestive of directional selection by ARTs. We further analyzed pfatp6 from a worldwide collection of 862 P. falciparum isolates in 19 populations from Asia, Africa, South America and Oceania, which include samples from regions prior to and after deployments ART drugs. A total of 71 SNPs were identified, resulting in 106 nucleotide haplotypes. Similarly, many of the mutations were continent-specific and present at frequencies below 5%. The most predominant and perhaps the ancestral haplotype occurred in 441 samples and was present in 16 populations from Asia, Africa, and Oceania. The 3D7 haplotype found in 54 samples was the second most common haplotype and present in nine populations from all four continents. Assessment of the selection strength on pfatp6 in the 19 parasite populations found that pfatp6 in most of these populations was under purifying selection with an average dN/dS ratio of 0.333. Molecular evolution analyses did not detect significant departures from neutrality in pfatp6 for most populations, challenging the suitability of this gene as a marker for monitoring ART resistance

Microgeography and molecular epidemiology of malaria at the Thailand-Myanmar border in the malaria pre-elimination phase

BACKGROUND: Endemic malaria in Thailand continues to only exist along international borders. This pattern is frequently attributed to importation of malaria from surrounding nations. A microgeographical approach was used to investigate malaria cases in a study village along the Thailand–Myanmar border. METHODS: Three mass blood surveys were conducted during the study period (July and December 2011, and May 2012) and were matched to a cohort-based demographic surveillance system. Blood slides and filter papers were taken from each participant. Slides were cross-verified by an expert microscopist and filter papers were analysed using nested PCR. Cases were then mapped to households and analysed using spatial statistics. A risk factor analysis was done using mixed effects logistic regression. RESULTS: In total, 55 Plasmodium vivax and 20 Plasmodium falciparum cases (out of 547 participants) were detected through PCR, compared to six and two (respectively) cases detected by field microscopy. The single largest risk factor for infection was citizenship. Many study participants were ethnic Karen people with no citizenship in either Thailand or Myanmar. This subpopulation had over eight times the odds of malaria infection when compared to Thai citizens. Cases also appeared to cluster near a major drainage system and year–round water source within the study village. CONCLUSION: This research indicates that many cases of malaria remain undiagnosed in the region. The spatial and demographic clustering of cases in a sub-group of the population indicates either transmission within the Thai village or shared exposure to malaria vectors outside of the village. While it is possible that malaria is imported to Thailand from Myanmar, the existence of undetected infections, coupled with an ecological setting that is conducive to malaria transmission, means that indigenous transmission could also occur on the Thai side of the border. Improved, timely, and active case detection is warranted

Prevalence of asymptomatic Plasmodium infections with sub-microscopic parasite densities in the northwestern border of Thailand: a potential threat to malaria elimination

Abstract Background Asymptomatic infections with sub-microscopic Plasmodium serve as a silent reservoir of disease, critical to sustaining a low level of remanent malaria in the population. These infections must be effectively identified and targeted for elimination. The sensitivity of light microscopy, the traditional method used for diagnosing Plasmodium infections, is frequently insufficient for detecting asymptomatic infections due to the low density of parasitaemia. The objective of this study was to explore the current prevalence of asymptomatic sub-microscopic Plasmodium carriages to evaluate the parasite reservoir amongst residents from 7 hamlets in Tak Province in northwestern Thailand using a highly sensitive molecular method. Methods Malaria infection was screened in a real-world setting from 3650 finger-prick blood specimens collected in a mass cross-sectional survey using light microscopy and loop-mediated isothermal amplification (LAMP). LAMP results were later confirmed in a laboratory setting in Bangkok using nested PCR, restriction enzyme digestion and DNA sequencing. The association of malaria infection with demographic factors was explored. Results Parasite prevalence was 0.27% (10/3650) as determined by microscopy. Sub-microscopic infection prevalence was 2.33% (85/3650) by LAMP. Of these, 30.6% (26/85) were infected with Plasmodium falciparum, 52.9% (45/85) with Plasmodium vivax, 2.4% (2/85) with Plasmodium malariae, 4.7% (4/85) with mixed P. falciparum and P. vivax, and 9.4% (8/85) had parasite densities too low for species identification. Asymptomatic carriages (T < 37.5 °C) accounted for 95% (76/80) of all sub-microscopic cases with the highest prevalence occurring in the subjects 31–45 years of age (p ≤ 0.035). Participants working on plantations or as merchants had an increased infection risk. Evaluation by microscopy identified 10.53% (10/95) of all Plasmodium infected participants. Conclusion Participants carrying asymptomatic Plasmodium infections with sub-microscopic parasite densities are considerable in this area. These findings provide the true disease burden and risk factors in this region. This information helps to direct policy makers towards better schemes and delivery of targeted interventions. Moreover, this is the first study to use LAMP in mass screening for sub-clinical and sub-microscopic infections in a field setting in Thailand. LAMP proves to be a sensitive and field-deployable assay suitable for national malaria control screening campaigns