Tracing the origins of Plasmodium vivax resurgence after malaria elimination on Aneityum Island in Vanuatu.

BACKGROUND: Five years after successful malaria elimination, Aneityum Island in Vanuatu experienced an outbreak of Plasmodium vivax of unknown origin in 2002. Epidemiological investigations revealed several potential sources of P. vivax. We aimed to identify the genetic origin of P. vivax responsible for the resurgence. METHODS: Five P. vivax microsatellite markers were genotyped using DNA extracted from archived blood samples. A total of 69 samples from four P. vivax populations was included: 29 from the outbreak in 2002, seven from Aneityum in 1999 and 2000, 18 from visitors to Aneityum in 2000, and 15 from nearby Tanna Island in 2002. A neighbour-joining phylogenetic tree was constructed to elucidate the relationships among P. vivax isolates. STRUCTURE and principal component analysis were used to assess patterns of genetic structure. RESULTS: Here we show distinct genetic origins of P. vivax during the outbreak on Aneityum. While the origin of most P. vivax lineages found during the outbreak remains unidentified, limited genetic diversity among these lineages is consistent with a rapid expansion from a recent common ancestor. Contemporaneous P. vivax from neighboring Tanna and potential relapse of P. vivax acquired from other islands in 1999 and 2000 are also identified as minor contributors to the outbreak. CONCLUSIONS: Multiple reintroductions of P. vivax after elimination highlight the high receptivity and vulnerability to malaria resurgence in island settings of Vanuatu, despite robust surveillance and high community compliance to control measures.

Plasmodium vivax is one of several parasite species that cause malaria. On Aneityum Island in Vanuatu, malaria had been eliminated in 1997, but an outbreak was reported in 2002 despite protective measures still being in place. Here, we analysed DNA of parasites from the outbreak to understand its origin, since parasites of different origins will have slight differences in their DNA. Most parasites had similar DNA suggesting they had a recent shared common ancestor whose origin remains unidentified. From this analysis we were also able to find a minority of parasites that likely came from Tanna in 2002, while another small group of parasites may have originated from parasites imported to Aneityum in 1999 or 2000. This illustrates the difficulty of maintaining a malaria-free status in resource-limited areas and the threat of imported malaria to elimination efforts.

The Utility of Malaria Rapid Diagnostic Tests as a Tool in Enhanced Surveillance for Malaria Elimination in Vanuatu.

BACKGROUND: As part of efforts to eliminate malaria, Vanuatu has piloted the implementation of enhanced malaria surveillance and response strategies since 2011. This involves passive case detection (PCD) in health facilities, proactive case detection (Pro-ACD) and reactive case detection (Re-ACD) in communities using malaria rapid diagnostic tests (RDTs). While RDTs improve case management, their utility for detection of malaria infections in ACDs in this setting is unclear. METHODS: The utility of malaria RDTs as diagnostic tools was evaluated in PCD, in five rounds of Pro-ACDs and five rounds of Re-ACDs conducted in Tafea and Torba Provinces between 2011 and 2014. The number of malaria infections detected by RDTs was compared to that detected by PCR from collected used-RDTs. RESULTS: PCD in Tafea Province (2013) showed a RDT-positive rate of 0.21% (2/939) and a PCR-positive rate of 0.44% (2/453), indicating less than 1% of suspected malaria cases in Tafea Province were due to malaria. In Pro-ACDs conducted in Tafea and Torba Provinces, RDT-positive rates in 2013 and 2014 were 0.14% (3/2145) and 0% (0/2823), respectively, while the corresponding PCR-positive rates were 0.72% (9/1242) and 0.79% (9/1141). PCR identified villages in both provinces appearing to be transmission foci with a small number of low-density infections, mainly P. falciparum infections. In five rounds of Re-ACD, RDTs did not identify any additional infections while PCR detected only one among 173 subjects screened. CONCLUSIONS: PCD and Pro-ACDs demonstrate that both Tafea and Torba Provinces in Vanuatu has achieved very low malaria prevalence. In these low-transmission areas, conducting Pro-ACD and Re-ACDs using RDTs appears not cost-effective and may have limited impact on interrupting malaria transmission due to the small number of infections identified by RDTs and considerable operational resources invested. More sensitive, field deployable and affordable diagnostic tools will improve malaria surveillance in malaria elimination settings.

Evaluating the feasibility of using insecticide quantification kits (IQK) for estimating cyanopyrethroid levels for indoor residual spraying in Vanuatu.

BACKGROUND: The quality of routine indoor residual spraying (IRS) operations is rarely assessed because of the limited choice of methods available for quantifying insecticide content in the field. This study, therefore, evaluated a user-friendly, rapid colorimetric assay for detecting insecticide content after routine IRS operations were conducted. METHODS: This study was conducted in Tafea Province, Vanuatu. Routine IRS was conducted with lambda cyhalothrin. Two methods were used to quantify the IRS activities: 1) pre-spray application of small felt pads and 2) post-spray removal of insecticide with adhesive. The insecticide content was quantified using a colorimetric assay (Insecticide Quantification Kit [IQK]), which involved exposing each sample to the test reagents for 15 mins. The concentration of insecticide was indicated by the depth of red colour. RESULTS: The IQK proved simple to perform in the field and results could be immediately interpreted by the programme staff. The insecticide content was successfully sampled by attaching felt pads to the house walls prior to spraying. The IRS operation was well conducted, with 83% of houses being sprayed at the target dose (20 - 30 mg AI/m2). The average reading across all houses was 24.4 ± 1.5 mg AI/m2. The results from the felt pads applied pre-spray were used as a base to compare methods for sampling insecticide from walls post-spray. The adhesive of Sellotape did not collect adequate samples. However, the adhesive of the felt pads provided accurate samples of the insecticide content on walls. CONCLUSION: The IQK colorimetric assay proved to be a useful tool that was simple to use under realistic field conditions. The assay provided rapid information on IRS spray dynamics and spray team performance, facilitating timely decision making and reporting for programme managers. The IQK colorimetric assay will have direct applications for routine quality control in malaria control programmes globally and has the potential to improve the efficacy of vector control operations.

Long-term insecticidal activity and physical integrity of Olyset nets in Tafea Province, Vanuatu.

The long-term efficacy of long-lasting insecticidal nets (LLINs) depends on both the physical condition of the net and the residual activity of the insecticide. This study focused on monitoring these parameters in Olyset nets (Sumitomo Chemical Co., Osaka, Japan) (n = 101) that had been used for 1-3 yr in Tafea Province, Vanuatu. Net usage and frequency of washing was ascertained by questionnaire; the nets were assessed with regards to cleanliness and damage owing to holes. Insecticide efficacy was determined with cone bioassays using Anophelesfarauti Laveran. Net usage was high and 86.1% (87 of 101) of villages stated that they used the net every night. Washing of nets was low (11.9%, 12 of 101), and most nets (79.2%, 80 of 101) were considered dirty. Most nets were damaged (73.4% had holes), and 22.8% (23 of 101) had large holes (>200 cm2). The 24-h mortality of An. farauti exposed to nets aged 1-2 yr was 79.4%, while the mortality for nets 3 yr of age was significantly lower at 73.7%. There was no difference in the insecticidal activity of clean compared with dirty nets (mean 24-h mortality: Clean = 76.7%, Dirty = 77.1%). Although the majority of nets had holes, the physical condition of 8.9-22.8% of nets was altered so severely to potentially affect efficacy. Although the 3-yr-old nets would still be providing significant levels of insecticidal and personal protection, consideration should be given to replacing nets >3 yr old.

A spatial decision support system for guiding focal indoor residual interventions in a malaria elimination zone.

A customized geographical information system (GIS) has been developed to support focal indoor residual spraying (IRS) operations as part of a scaled-up campaign to progressively eliminate malaria in Vanuatu. The aims of the GISbased spatial decision support system (SDSS) were to guide the planning, implementation and assessment of IRS at the household level. Additional aims of this study were to evaluate the user acceptability of a SDSS guiding IRS interventions. IRS was conducted on Tanna Island, Republic of Vanuatu between 26 October and 5 December 2009. Geo-referenced household information provided a baseline within the SDSS. An interactive mapping interface was used to delineate operation areas, extract relevant data to support IRS field teams. In addition, it was used as a monitoring tool to assess overall intervention coverage. Surveys and group discussions were conducted during the operations to ascertain user acceptability. Twenty-one operation areas, comprising a total of 187 settlements and 3,422 households were identified and mapped. A total of 3,230 households and 12,156 household structures were sprayed, covering a population of 13,512 individuals, achieving coverage of 94.4% of the households and 95.7% of the population. Village status maps were produced to visualize the distribution of IRS at the sub-village level. One hundred percent of survey respondents declared the SDSS a useful and effective tool to support IRS. The GIS-based SDSS adopted in Tanna empowered programme managers at the provincial level to implement and asses the IRS intervention with the degree of detail required for malaria elimination. Since completion, SDSS applications have expanded to additional provinces in Vanuatu and the neighbouring Solomon Islands supporting not only specific malaria elimination and control interventions, but also the broader public health sector in general.