Landier J, et al. - Researchers sought to ascertain the effects of a scaled-up programme of mass drug administration in four townships of eastern Myanmar on the incidence of P falciparum malaria. A substantial decrease in the village-level incidence of artemisinin-resistant P falciparum malaria in hard-to-reach, politically sensitive regions of eastern Myanmar was noted in association with providing early diagnosis and effective treatment. In hotspots, significantly reduced malaria incidence was observed with targeted mass drug administration. Subnational elimination of P falciparum could be achieved if these activities could proceed in all contiguous endemic areas in addition to standard control programmes already implemented.

Methods

• In the four townships of Myawaddy, Kawkareik, Hlaingbwe, and Hpapun in Kayin state, Myanmar, the programme was implemented.
• Provision of increased access to early diagnosis and treatment of malaria to all villages was performed via community-based malaria posts equipped with rapid diagnostic tests, and treatment with artemether–lumefantrine plus single low-dose primaquine.
• Researchers identified villages as malarial hotspots (operationally defined as >40% malaria, of which 20% was P falciparum) with surveys using ultrasensitive quantitative PCR either randomly or targeted at villages where the incidence of clinical cases of P falciparum malaria remained high (ie, >100 cases per 1000 individuals per year) despite a functioning malaria post.
• They obtained a 2 mL sample of venous blood from randomly selected adults during each survey.
• In this study, hotspots received targeted mass drug administration with dihydroartemisinin–piperaquine plus single-dose primaquine once per month for 3 consecutive months in addition to the malaria posts.
• The change in village incidence of clinical P falciparum malaria was the main outcome measure; this was quantified using a multivariate, generalised, additive multilevel model.
• In the hotspots, they measured malaria prevalence 12 months after mass drug administration.

Results

• One thousand two hundred and twenty two malarial posts were opened between May 1, 2014, and April 30, 2017.
• The malarial posts provided early diagnosis and treatment to an estimated 365,000 individuals.
• The four townships demonstrated a decrease in incidence of P falciparum malaria by 60 to 98%.
• Researchers undertook 272 prevalence surveys and identified 69 hotspot villages.
• Fifty hotspots were treated with mass drug administration by April 2017.
• A three times higher incidence of P falciparum was noted at malarial posts in hotspot villages than neighbouring villages (adjusted incidence rate ratio [IRR] 2·7, 95% CI 1·8–4·4).
• They noted a significant decrease in P falciparum incidence via early diagnosis and treatment in hotspots (IRR 0·82, 95% CI 0·76–0·88 per quarter) and in other villages (0·75, 0·73–0·78 per quarter).
• Within hotspot villages, mass drug administration was noted to be associated with a five-times decrease in P falciparum incidence (IRR 0·19, 95% CI 0·13–0·26).
• Nine hundred and sixty five villages (79%) of 1222 corresponding to 104 village tracts were free from P falciparum malaria for at least 6 months by April, 2017.
• Over the 3 years, stable prevalence of wild-type genotype for K13molecular markers of artemisinin resistance was noted(39%; 249/631).