Changing epidemiology of Plasmodium vivax malaria in Nouakchott, Mauritania: a six-year (2015-2020) prospective study.

BACKGROUND: Plasmodium vivax malaria is one of the major infectious diseases of public health concern in Nouakchott, the capital city of Mauritania and the biggest urban setting in the Sahara. The assessment of the current trends in malaria epidemiology is primordial in understanding the dynamics of its transmission and developing an effective control strategy. METHODS: A 6 year (2015-2020) prospective study was carried out in Nouakchott. Febrile outpatients with a clinical suspicion of malaria presenting spontaneously at Teyarett Health Centre or the paediatric department of Mother and Children Hospital Centre were screened for malaria using a rapid diagnostic test, microscopic examination of Giemsa-stained blood films, and nested polymerase chain reaction. Data were analysed using Microsoft Excel and GraphPad Prism and InStat software. RESULTS: Of 1760 febrile patients included in this study, 274 (15.5%) were malaria-positive by rapid diagnostic test, 256 (14.5%) were malaria-positive by microscopy, and 291 (16.5%) were malaria-positive by PCR. Plasmodium vivax accounted for 216 of 291 (74.2%) PCR-positive patients; 47 (16.1%) and 28 (9.6%) had P. falciparum monoinfection or P. vivax-P. falciparum mixed infection, respectively. During the study period, the annual prevalence of malaria declined from 29.2% in 2015 to 13.2% in 2019 and 2.1% in 2020 (P < 0.05). Malaria transmission was essentially seasonal, with a peak occurring soon after the rainy season (October-November), and P. vivax infections, but not P. falciparum infections, occurred at low levels during the rest of the year. The most affected subset of patient population was adult male white and black Moors. The decline in malaria prevalence was correlated with decreasing annual rainfall (r = 0.85; P = 0.03) and was also associated with better management of the potable water supply system. A large majority of included patients did not possess or did not use bed nets. CONCLUSIONS: Control interventions based on prevention, diagnosis, and treatment should be reinforced in Nouakchott, and P. vivax-specific control measures, including chloroquine and 8-aminoquinolines (primaquine, tafenoquine) for treatment, should be considered to further improve the efficacy of interventions and aim for malaria elimination.

First report of Anopheles (Cellia) multicolor during a study of tolerance to salinity of Anopheles arabiensis larvae in Nouakchott, Mauritania.

BACKGROUND: Anopheles multicolor is known to be present in the arid areas of Africa north of the Sahara Desert, especially in oases. To date, its presence in Mauritania has not been reported. Here, we present the first record of its presence in Nouakchott, the capital of Mauritania. The larvae of An. multicolor, together with those of An. arabiensis, the major malaria vector in the city, were found thriving in highly saline surface water collections. METHODS: Entomological surveys were carried out during 2016-2017 in Nouakchott. Mosquito larval habitats were investigated through larval surveys while indoor resting culicid fauna were collected using hand-held aspirator. Physicochemical parameters of the larval habitats were measured on-site, at the time mosquitoes were collected. Larvae and pupae were reared to adults in the insectaries. Morphological and polymerase chain reaction (PCR)-based methods were used to identify newly emerged adults. Batches of fourth-instar larvae were used to assess salinity tolerance by exposing them to increasing concentrations of NaCl, and mortality was monitored throughout development. RESULTS: Morphological and molecular results confirmed that the specimens were An. multicolor and An. arabiensis. Sequences of 24 An. multicolor adult mosquitoes showed 100% nucleotide identity with the published sequences of An. multicolor from Iran. The physicochemical analysis of the water from the two larval habitats revealed highly saline conditions, with NaCl content ranging between 16.8 and 28.9 g/l (i.e. between c.50-80% seawater). Anopheles multicolor and An. arabiensis fourth-instar larvae survival rates at 17.5 g/l NaCl were 86.5% and 75%, respectively. Anopheles arabiensis larvae showed variable levels of salt tolerance according to the larval habitat. Adult An. multicolor specimens were collected resting indoor at low frequency (0.7%) compared to the other culicid mosquitoes. CONCLUSIONS: To the best of our knowledge, this paper is the first report of An. multicolor in Mauritania, extending the known distributional range of the species to the south, as well as to the west. Highly salt-tolerant populations of An. arabiensis and An. multicolor were observed. Because salt-water collections are widespread in Nouakchott, the relevance of these findings for the dynamics and epidemiology of malaria transmission needs to be assessed.

Characterization of Plasmodium falciparum genes associated with drug resistance in Hodh Elgharbi, a malaria hotspot near Malian-Mauritanian border.

BACKGROUND: A malaria hotspot in the southeastern region of Mauritania, near the Malian border, may hamper malaria control strategies. The objectives were to estimate the prevalence of genetic polymorphisms associated with drug resistance in Plasmodium falciparum isolates and establish baseline data. METHODS: The study was conducted in two malaria-endemic areas in Hodh Elgharbi, situated in the Malian-Mauritanian border area. Blood samples were collected from symptomatic patients. Single nucleotide polymorphisms in Pfcrt, Pfmdr1, Pfdhfr, and Pfdhps were genotyped using PCR-restriction fragment length polymorphism, DNA sequencing and primer extension. The Pfmdr1 gene copy number was determined by real-time PCR. RESULTS: Of 280 P. falciparum-infected patients, 193 (68.9%) carried the Pfcrt 76T mutant allele. The Pfmdr1 86Y and 184F mutations were found in 61 (23.1%) of 264 isolates and 167 (67.6%) of 247 samples that were successfully genotyped, respectively. Pfmdr1 mutant alleles 1034C, 1042D and 1246Y were rarely observed. Of 102 P. falciparum isolates analysed, ten (9.8%) had more than one copy of Pfmdr1 gene. The prevalence of isolates harbouring at least triple mutant Pfdhfr 51I, 59R, 108 N/T was 42% (112/268), of which 42 (37.5%) had an additional Pfdhps 437G mutation. The Pfdhps 540E mutation was observed in four isolates (1.5%), including three associated with Pfdhfr triple mutant. Only two quintuple mutants (Pfdhfr-51I-59R-108N Pfdhps-437G-540E) were observed. CONCLUSIONS: The observed mutations in Pfdhfr, Pfdhps, Pfmdr1, and Pfcrt may jeopardize the future of seasonal malaria chemoprevention based on amodiaquine-sulfadoxine-pyrimethamine, intermittent preventive treatment for pregnant women using sulfadoxine-pyrimethamine, and treatment with artesunate-amodiaquine. Complementary studies should be carried out to document the distribution, origin and circulation of P. falciparum populations in this region and more widely in the country to assess the risk of the spread of resistance.

Mosquitoes (Diptera: Culicidae) in Mauritania: a review of their biodiversity, distribution and medical importance.

Although mosquitoes (Diptera: Culicidae) are important disease vectors, information on their biodiversity in Mauritania is scarce and very dispersed in the literature. Data from the scientific literature gathered in the country from 1948 to 2016 were collected and analyzed. Overall 51 culicid species comprising 17 Anopheles spp., 14 Aedes spp., 18 Culex spp. and two Mansonia spp. have been described in Mauritania among which Anopheles arabiensis, Aedes vexans, Culex poicilipes and Culex antennatus are of epidemiological significance. Anopheles arabiensis is widely distributed throughout the country and its geographic distribution has increased northwards in recent years, shifting its northern limit form 17°32'N in the 1960s to 18°47'N today. Its presence in the central region of Tagant highlights the great ecological plasticity of the species. Conversely, the distribution of Anopheles gambiae (s.s.) and Anopheles melas has shrunk compared to that of the 1960s. Anopheles rhodesiensis and An. d'thali are mainly confined in the mountainous areas (alt. 200-700 m), whereas Anopheles pharoensis is widely distributed in the Senegal River basin. Culex poicilipes and Cx. antenattus were naturally found infected with Rift valley fever virus in central and northern Mauritania following the Rift valley outbreaks of 1998 and 2012. Recently, Ae. aegypti emerged in Nouakchott and is probably responsible for dengue fever episodes of 2015. This paper provides a concise and up-to-date overview of the existing literature on mosquito species known to occur in Mauritania and highlights areas where future studies should fill a gap in knowledge about vector biodiversity. It aims to help ongoing and future research on mosquitoes particularly in the field of medical entomology to inform evidence-based decision-making for vector control and management strategies.

Aedes aegypti (Diptera: Culicidae) in Mauritania: First Report on the Presence of the Arbovirus Mosquito Vector in Nouakchott.

Aedes aegypti L. (Diptera: Culicidae) is a major vector of yellow fever, dengue, and chikungunya viruses throughout tropical and subtropical areas of the world. Although the southernmost part of Mauritania along the Senegal river has long been recognized at risk of yellow fever transmission, Aedes spp. mosquitoes had never been reported northwards in Mauritania. Here, we report the first observation of Aedes aegypti aegypti (L.) and Aedes (Ochlerotatus) caspius (Pallas, 1771) in the capital city, Nouakchott. We describe the development sites in which larvae of the two species were found, drawing attention to the risk for emergence of arbovirus transmission in the city.

Malaria-associated morbidity during the rainy season in Saharan and Sahelian zones in Mauritania.

Reliable epidemiological data based on laboratory-confirmed cases are scarce in Mauritania. A large majority of reported malaria cases are based on presumptive clinical diagnosis. The present study was conducted to establish a reliable database on malaria morbidity among febrile paediatric and adult patients consulting spontaneously at public health facilities in Nouakchott, situated in the Saharan zone, and in Hodh Elgharbi region in the Sahelian zone in south-east Mauritania during the peak transmission periods. Giemsa-stained thin and thick films were examined under the microscope, and the parasite density was determined according to the procedures recommended by the World Health Organization. Microscopy results were confirmed by rapid diagnostic test for malaria. A total of 1161 febrile patients (498 in Nouakchott and 663 in Hodh Elgharbi region) were enrolled during two successive peak transmission periods in 2009 and 2010. In Nouakchott, 253 (50.8%) febrile patients had positive smears (83% Plasmodium vivax monoinfections and 17% Plasmodium falciparum monoinfections). In Hodh Elgharbi, 378 of 663 patients (57.0%) were smear-positive, mostly due to P. falciparum monoinfections (96.6%). Unlike in Nouakchott, mixed P. falciparum-P. vivax infections, as well as P. vivax, P. ovale, and P. malariae monoinfections, were also observed at a very low prevalence in southern Mauritania. In Nouakchott, malaria occurred more frequently (P<0.05) with higher slide positivity rates (42-53%) among children aged >5 years old and adults than in young children aged <5 years old in both 2009 and 2010. In Hodh Elgharbi, high slide positivity rates (60.9-86.2%) were observed in all age groups in 2010, and there was no significant trend (P>0.05) in relation with age groups. The present study confirmed the predominance of P. falciparum in southern Mauritania reported in previous studies. The presence of P. vivax in Nouakchott is a new epidemiological reality that requires an urgent adoption of novel strategies for parasitological and vector control to combat urban malaria. Moreover, the present study provides evidence-based data on malaria burden in two regions in Mauritania that may serve as a springboard to establish and develop a national surveillance system of malaria epidemiology.

Increasing prevalence of Plasmodium vivax among febrile patients in Nouakchott, Mauritania.

The occurrence of Plasmodium vivax malaria was reported in Nouakchott, Mauritania in the 1990s. Several studies have suggested the frequent occurrence of P. vivax malaria among Nouakchott residents, including those without recent travel history to the southern part of the country where malaria is known to be endemic. To further consolidate the evidence for P. vivax endemicity and the extent of malaria burden in one district in the city of Nouakchott, febrile illnesses were monitored in 2012-2013 in the Teyarett health center. The number of laboratory-confirmed P. vivax cases has attained more than 2,000 cases in 2013. Malaria transmission occurs locally, and P. vivax is diagnosed throughout the year. Plasmodium vivax malaria is endemic in Nouakchott and largely predominates over Plasmodium falciparum.

Molecular surveillance of drug-resistant Plasmodium vivax using pvdhfr, pvdhps and pvmdr1 markers in Nouakchott, Mauritania.

OBJECTIVES: Plasmodium falciparum and Plasmodium vivax occur in Mauritania. Drug-resistant P. falciparum has been reported, but the drug-resistance status of P. vivax is unknown. The aims of the present study were to determine the prevalence of mutant pvdhfr, pvdhps and pvmdr1 genes and of pvmdr1 gene amplification in P. vivax isolates in Nouakchott, the capital city of Mauritania, and to establish a baseline for molecular surveillance of drug-resistant P. vivax in the country. PATIENTS AND METHODS: Between 2007 and 2009, 439 febrile patients were screened for malaria in Nouakchott. The sequences of pvdhfr, pvdhps and pvmdr1 markers in 110 P. vivax isolates were determined by direct sequencing of PCR products. The pvmdr1 gene copy number was determined by real-time PCR. RESULTS: The majority of the isolates with a successful PCR amplification (76/86, 88%) were characterized to be of the wild-type pvdhfr genotype, while the remaining 10 isolates carried the S58R and S117N double mutations. All isolates had the wild-type pvdhps genotype SAKAV. For pvmdr1, 75 of 103 (73%) had the wild-type Y976, and 28 (27%) carried the mutant F976. Most (98%) carried the mutant L1076 codon. Of 105 isolates, 102 (97%) had one copy and 3 (3%) had two copies of the pvmdr1 gene. CONCLUSIONS: The prevalence of mutations associated with antifolate resistance is low in Mauritania. Further studies are required to determine the roles of pvmdr1 mutations and gene amplification in conferring drug resistance. These data will serve as a baseline for further monitoring of drug-resistant malaria.

Vivax malaria in Mauritania includes infection of a Duffy-negative individual.

BACKGROUND: Duffy blood group polymorphisms are important in areas where Plasmodium vivax is present because this surface antigen is thought to act as a key receptor for this parasite. In the present study, Duffy blood group genotyping was performed in febrile uninfected and P. vivax-infected patients living in the city of Nouakchott, Mauritania. METHODS: Plasmodium vivax was identified by real-time PCR. The Duffy blood group genotypes were determined by standard PCR followed by sequencing of the promoter region and exon 2 of the Duffy gene in 277 febrile individuals. Fisher's exact test was performed in order to assess the significance of variables. RESULTS: In the Moorish population, a high frequency of the FYBES/FYBES genotype was observed in uninfected individuals (27.8%), whereas no P. vivax-infected patient had this genotype. This was followed by a high level of FYA/FYB, FYB/FYB, FYB/FYBES and FYA/FYBES genotype frequencies, both in the P. vivax-infected and uninfected patients. In other ethnic groups (Poular, Soninke, Wolof), only the FYBES/FYBES genotype was found in uninfected patients, whereas the FYA/FYBES genotype was observed in two P. vivax-infected patients. In addition, one patient belonging to the Wolof ethnic group presented the FYBES/FYBES genotype and was infected by P. vivax. CONCLUSIONS: This study presents the Duffy blood group polymorphisms in Nouakchott City and demonstrates that in Mauritania, P. vivax is able to infect Duffy-negative patients. Further studies are necessary to identify the process that enables this Duffy-independent P. vivax invasion of human red blood cells.