Different spatial distribution of Aedes aegypti and Aedes albopictus along an urban-rural gradient and the relating environmental factors examined in three villages in northern Thailand.

A larval survey of dengue vectors was conducted from July to November 1966 and from May to November 1997 in Chiangmai Province, Thailand. Three villages in urban, transition, and rural areas were selected for the survey to clarify the spatial distribution of Ae. aegypti and Ae. albopictus along an urban-rural ecological gradient. The average number of Ae. aegypti larvae in larvitraps was higher in the urban area than in the rural area, as we expected, whereas the opposite was found for Ae. albopictus, rural area > urban area. A house survey of larvae-inhabiting containers showed significant differences in the number and composition of these containers among the study areas. Significant differences were also found in the average distance between houses, average tree height, and average percentage of vegetation cover for each house. The seasonal pattern of rainfall recorded in each study area did not show great differences among the study areas. The response of Ae. aegypti and Ae. albopictus to the urban-rural gradient is discussed in relation to the possibility of applying geographic information system techniques to plan the control strategy and surveillance of dengue vectors.

Infectious reservoir of Plasmodium infection in Mae Hong Son Province, north-west Thailand.

BACKGROUND: It was unknown whether the main reservoir of Plasmodium falciparum and Plasmodium vivax, which infects mosquitoes in Thailand, was (a) in people feeling sufficiently ill with malaria to come to a clinic or (b) in people who had remained in their home villages with some fever symptoms or with none. METHODS: Mass surveys were carried out in Thai villages to identify people with Plasmodium infections and with fever. Malaria patients were also located at a clinic which served these villages. Adults from both sources whose blood slides registered positive for Plasmodium spp. were requested to allow laboratory-bred Anopheles minimus to feed on them. Seven to nine days after the blood feeds the mosquitoes were dissected and checked for presence of oocysts. RESULTS AND DISCUSSION: There were higher rates of Plasmodium infection among people in the villages with fever than without fever and much higher rates of infection among clinic patients than among people who had remained in the villages. People with malarial infections identified via the clinic and the village surveys could infect mosquitoes, especially, but not only, if their blood slides showed visible gametocytes. Because only a very small minority of the village populations were visiting the clinic on any one day, assessment indicated that the main reservoir of infection was not primarily among clinic patients but among those in the villages, especially those feeling feverish. CONCLUSIONS: Efficient use of an anti-gametocyte drug to suppress the parasite reservoir in a population requires that it be given, not just to clinic patients, but to infected people located by mass surveys of the villages, especially those feeling feverish.

Mefloquine--its 20 years in the Thai Malaria Control Program.

Due to the deteriorating efficacy of sulfadoxine-pyrimethamine (SP or Fansidar), from the mid-1970s the Thai Malaria Control Program was actively involved in testing potential replacement drugs to be used as the primary therapy for falciparum malaria in Thailand. In 1983, a large-scale field trial of mefloquine, a long-acting antimalarial drug known for its efficacy against chloroquine- and SP-resistant Plasmodium falciparum, was initiated on the Thai-Cambodian border. The study enrolled over 60,000 patients and eventually led to the formal establishment of mefloquine as the first line drug for the treatment of uncomplicated falciparum malaria in the country. Mefloquine has played a significant role in the control of malaria in Thailand for the past two decades, initially in combination with SP, then by itself, and currently in selected areas as a partner drug in the combination therapy with artesunate. Thailand is the country with the most experience in the use of this drug in a malaria control program. We present here a review of mefloquine's pharmacology and usage in Thailand.

Changes in malaria vector densities over a twenty-three year period in Mae Hong Son Province, northern Thailand.

Mae Hong Son Province in northwestern Thailand has a long history of malaria. During the last two decades the province has had one of the highest malaria incidences of all provinces in Thailand. Data were analyzed to determine whether the vector populations were stable or increasing during the last two decades and to determine the seasonal prevalence of the main vectors, and whether or not they were related to the malaria transmission peak, in the wet season. We compiled and analyzed accumulated entomological records from 1977 to 1999. The aim was to investigate long-term changes in mean densities of malaria vectors between two periods (1977-1989 and 1990-1999), and the differences in vector densities between two seasons (wet and dry). A total of 141,144 adult anophelines of 29 species were collected on indoor and outdoor human baits and animal baits during the study period. Of the main malaria vectors, the densities of Anopheles minimus s.l. and Anopheles maculatus complex increased significantly. Anopheles dirus s.l., however, was stable between the two periods. These vector populations were associated with consistently high malaria incidence in the province during the last two decades. An. minimus s.l. density was not significantly different between seasons. However, in the second period, both An. dirus s.l. and An. maculatus complex showed a tendency for higher wet season densities. This can explain the high malaria incidence in the rainy season in Mae Hong Son. Environmental and climatic factors seem to have been favorable for supporting a consistently high vector population in the province, and consequently a high malaria transmission rate during the period of study.

Comparative study of the in vitro sensitivity of Plasmodium falciparum to artemisinin in two border areas of Thailand.

Artesunate was introduced in Thailand in 1995 for the treatment of falciparum malaria in areas of multidrug resistance, where it is used in combination with mefloquine. The studies were conducted between May and August 1999, 2000 and 2001 in the provinces Mae Hong Son and Tak (Mae Sot District) in northwestern Thailand, both on the border to Myanmar. The province of Mae Hong Son is still largely unaffected by multidrug resistance and infections with Plasmodium falciparum are treated with mefloquine alone. In the district of Mae Sot, 350 km southwards, more than 60% of the Plasmodium falciparum isolates were found to be resistant to mefloquine. Between 1999 and 2001, a total of 227 fresh isolates of Plasmodium falciparum were successfully tested for their sensitivity to artemisinin using the WHO standard in vitro microtest. The weighted mean EC5o and EC90 values for 1999-2001 were 9.20 nM and 34.37 nM in Mae Hong Son and 11.18nM and 71.63nM in Mae Sot, respectively. The comparison of the sensitivity to artemisinin between Mae Hong Son and Mae Sot showed no significant difference in 1999, but significant differences in 2000 (p<0.05) and in 2001 (p<0.01). This phenomenon could be a consequence of different drug pressure. Furthermore, the lower sensitivity of Plasmodium falciparum to mefloquine in Mae Sot may play a minor (but amplifying) role, as the activities of artemisinin and mefloquine show a significant correlation.

Mekong malaria. II. Update of malaria, multi-drug resistance and economic development in the Mekong region of Southeast Asia.

In an expansion of the first Mekong Malaria monograph published in 1999, this second monograph updates the malaria database in the countries comprising the Mekong region of Southeast Asia. The update adds another 3 years' information to cover cumulative data from the 6 Mekong countries (Cambodia, China/Yunnan, Lao PDR, Myanmar, Thailand, Viet Nam) for the six-year period 1999-2001. The objective is to generate a more comprehensive regional perspective in what is a global epicenter of drug resistant falciparum malaria, in order to improve malaria control on a regional basis in the context of social and economic change. The further application of geographical information systems (GIS) to the analysis has underscored the overall asymmetry of disease patterns in the region, with increased emphasis on population mobility in disease spread. Of great importance is the continuing expansion of resistance of P. falciparum to antimalarial drugs in common use and the increasing employment of differing drug combinations as a result. The variation in drug policy among the 6 countries still represents a major obstacle to the institution of region-wide restrictions on drug misuse. An important step forward has been the establishment of 36 sentinel sites throughout the 6 countries, with the objective of standardizing the drug monitoring process; while not all sentinel sites are fully operational yet, the initial implementation has already given encouraging results in relation to disease monitoring. Some decreases in malaria mortality have been recorded. The disease patterns delineated by GIS are particularly instructive when focused on inter-country distribution, which is where more local collaborative effort can be made to rationalize resource utilization and policy development. Placing disease data in the context of socio-economic trends within and between countries serves to further identify the needs and the potential for placing emphasis on resource rationalization on a regional basis. Despite the difficulties, the 6-year time frame represented in this monograph gives confidence that the now well established collaboration is becoming a major factor in improving malaria control on a regional basis and hopefully redressing to a substantial degree the key problem of spread of drug resistance regionally and eventually globally.

In-vitro interaction of tafenoquine and chloroquine in Plasmodium falciparum from northwestern Thailand.

The blood schizontocidal, pharmacodynamic interaction between tafenoquine (WR 238605--a 5-phenoxyprimaquine derivative--and chloroquine was investigated, using an in-vitro test for the inhibition of schizont maturation, in 15 fresh isolates of Plasmodium falciparum that originated from northwestern Thailand and neighbouring Myanmar. In this area the parasite is highly resistant to chloroquine. The geometric mean cut-off concentrations of schizont maturation for tafenoquine and chloroquine were 5261 nM and 7638 nM, respectively. With a mixture of tafenoquine and chloroquine, the mean cut-off concentration was 5252 nM, corresponding to 389 nM tafenoquine + 4863 nM chloroquine. Further analysis showed that the interaction between tafenoquine and chloroquine was additive within the range of EC20 and EC77. At concentrations higher than the EC77, interaction was moderately synergistic. While tafenoquine did not reverse the resistance to chloroquine to the degree of clinically relevant sensitivity, there was evidence that the blood schizontocidal efficacy of tafenoquine would be enhanced in the presence of chloroquine.

Comparison of the in-vitro activity of amodiaquine and its main metabolite, monodesethyl-amodiaquine, in Plasmodium falciparum.

After its rehabilitation for therapeutic use in uncomplicated falciparum malaria, there is renewed interest in amodiaquine. After oral administration, the drug undergoes rapid metabolism to monodesethyl-amodiaquine, and in patients with normal hepatic function the parent drug usually becomes undetectable within a few hours. The main antimalarial activity is therefore mainly due to the metabolite. In a comparative study in northwestern Thailand, 21 fresh isolates of Plasmodium falciparum were tested, in parallel, for their in-vitro sensitivity to both compounds, using the WHO micro-test Mark II, measuring the inhibition of schizont maturation. The geometric mean cut-off concentrations of schizont maturation were 1826 nM (related to blood) for amodiaquine, and 1654 nM for monodesethyl-amodiaquine. The log-probit regressions for both compounds showed good fits to the data points. The EC50 values were 331 nM and 291 nM, and the EC90 values 1337 nM and 993 nM for amodiaquine and monodesethyl-amodiaquine, respectively. Differences between regression slopes and effective concentrations were well below statistical significance. Both compounds showed highly significant activity correlation. These findings suggest that the sensitivity of Plasmodium falciparum to amodiaquine closely reflects its sensitivity to monodesethyl-amodiaquine.

In-vitro sensitivity testing of Plasmodium vivax: response to lumefantrine and chloroquine in northwestern Thailand.

The acquisition of resistance to chloroquine by Plasmodium vivax in parts of the Australasian and Malaysian epidemiological zones and hitherto unconfirmed reports of such resistance in neighbouring zones show the need for monitoring the drug response of P. vivax. In this study, a recently developed in-vitro micro-technique for the assessment of the parasite's sensitivity to chloroquine was adapted to and validated for lumefantrine. In 21 P. vivax isolates tested at Mae Hong Son, northwestern Thailand, in 2001, the mean geometric cut-off concentration for full inhibition for lumefantrine was 2080 nM. The EC50 and EC90 were 12 nM and 237 nM, respectively. The response was well within the putative therapeutic range. Sensitivity to chloroquine was assessed in 18 P. vivax isolates, showing a geometric mean cut-off concentration of 1095 nM and a wider variation of the individual cut-off points compared with lumefantrine. The EC50 and EC90 for chloroquine were 16 nM and 511 nM, respectively. One of the isolates, from Myanmar, showed low sensitivity to chloroquine.

Genetic structure of Aedes aegypti populations in Chiang Mai (Thailand) and relation with dengue transmission.

We analysed the population genetic structure and differentiation regarding vector competence for a dengue virus of 15 Aedes aegypti samples collected from Chiang Mai in northern Thailand. Based on polymorphism of 10 isoenzyme loci, genetic differentiation was confirmed among samples collected in different subdistricts (high FST values and P < 0.05). Based on infection rate for a dengue 2 virus, susceptibilities were similar in mosquitoes collected in San Nuea subdistrict and in Choeng Doi subdistrict, and were heterogeneous in populations sampled in other subdistricts. These findings are discussed and related to insecticide treatments.

Pharmacodynamic interaction of doxycycline and artemisinin in Plasmodium falciparum.

Parallel in vitro tests, assessing the inhibition of schizont maturation, were conducted with 31 fresh isolates of Plasmodium falciparum from Thailand, using artemisinin, doxycycline, and combinations of both. The activities of artemisinin and doxycycline are obviously not correlated. Both compounds showed consistent synergism at 50% effective concentration (EC(50)), EC(90), and EC(99) levels.