Understanding and maximising the community impact of seasonal malaria chemoprevention in Burkina Faso (INDIE-SMC): study protocol for a cluster randomised evaluation trial.

INTRODUCTION: Seasonal malaria chemoprevention (SMC) involves repeated administrations of sulfadoxine-pyrimethamine plus amodiaquine to children below the age of 5 years during the peak transmission season in areas of seasonal malaria transmission. While highly impactful in reducing Plasmodium falciparum malaria burden in controlled research settings, the impact of SMC on infection prevalence is moderate in real-life settings. It remains unclear what drives this efficacy decay. Recently, the WHO widened the scope for SMC to target all vulnerable populations. The Ministry of Health (MoH) in Burkina Faso is considering extending SMC to children below 10 years old. We aim to assess the impact of SMC on clinical incidence and parasite prevalence and quantify the human infectious reservoir for malaria in this population. METHODS AND ANALYSIS: We will perform a cluster randomised trial in Saponé Health District, Burkina Faso, with three study arms comprising 62 clusters of three compounds: arm 1 (control): SMC in under 5-year-old children, implemented by the MoH without directly observed treatment (DOT) for the full course of SMC; arm 2 (intervention): SMC in under 5-year-old children, with DOT for the full course of SMC; arm 3 (intervention): SMC in under 10-year-old children, with DOT for the full course of SMC. The primary endpoint is parasite prevalence at the end of the malaria transmission season. Secondary endpoints include the impact of SMC on clinical incidence. Factors affecting SMC uptake, treatment adherence, drug concentrations, parasite resistance markers and transmission of parasites will be determined. ETHICS AND DISSEMINATION: The London School of Hygiene & Tropical Medicine's Ethics Committee (29193) and the Burkina Faso National Medical Ethics Committee (Deliberation No 2023-05-104) approved this study. The findings will be presented to the community; disease occurrence data and study outcomes will also be shared with the Burkina Faso MoH. Findings will be published irrespective of their results. TRIAL REGISTRATION NUMBER: NCT05878366.

Naturally acquired immune responses to Plasmodium falciparum sexual stage antigens Pfs48/45 and Pfs230 in an area of seasonal transmission.

Acquisition of immunity to Plasmodium falciparum sexual stages is a key determinant for reducing human-mosquito transmission by preventing the fertilization and the development of the parasite in the mosquito midgut. Naturally acquired immunity against sexual stages may therefore form the basis for the development of transmission-blocking vaccines, but studies conducted to date offer little in the way of consistent findings. Here, we describe the acquisition of antigametocyte immune responses in malaria-exposed individuals in Burkina Faso. A total of 719 blood samples were collected in a series of three cross-sectional surveys at the start, peak, and end of the wet season. The seroprevalence of antibodies with specificity for the sexual stage antigens Pfs48/45 and Pfs230 was 2-fold lower (22 to 28%) than that for an asexual blood stage antigen glutamate-rich protein (GLURP) (65%) or for the preerythrocytic stage antigen circumsporozoite protein (CSP) (54%). The youngest children responded at frequencies similar to those for all four antigens but, in contrast with the immune responses to GLURP and CSP that increased with age independently of season and area of residence, there was no evidence for a clear age dependence of responses to Pfs48/45 and Pfs230. Anti-Pfs230 antibodies were most prevalent at the peak of the wet season (P < 0.001). Our findings suggest that naturally acquired immunity against Pfs48/45 and Pfs230 is a function of recent exposure rather than of cumulative exposure to gametocytes.

Cost of integrated vector control with improved sanitation and road infrastructure coupled with the use of slow-release Bacillus sphaericus granules in a tropical urban setting.

A field test of integrated vector control was conducted in a tropical urban setting with a combination of a floating, slow-release, granular formulation of Bacillus sphaericus and environmental engineering measures (renovation of roads, collective water pumps, and cesspool lids). The targets were Culex quinquefasciatus and Anopheles gambiae in the two biggest towns of Burkina Faso (West Africa). Within the intervention zone, water pumping stations were improved and the surroundings drained to prevent the accumulation of stagnant water. Roads were leveled and given either simple gutters on each side or a concrete channel on one side to drain runoff water. Garbage containers were installed to provide an alternative to the drainage channels for waste disposal. Septic tanks were modified so that they could be emptied without destroying their lid. This study showed that it is possible to implement mosquito control in a tropical urban environment with teams of young people rapidly trained to apply a biological larvicide without any tools other than an iron bar to lift cesspool lids. Environmental improvements were initially costly, but demanded little subsequent expenditure. Local inhabitants' committees were mobilized to provide people with information and monitor the efficacy of the measures. Compared with what people spent individually on mosquito prevention and malaria medicine, these measures were not expensive, but many expected the community to pay for them from existing taxes, e.g., for water treatment and disposal. The necessary funding and logistics require a municipal organization with neighborhood support, if the measures are to be effective.

Temporal dynamics of malaria transmission in two rural areas of Burkina Faso with two ecological differences.

To determine the relationship between malaria transmission intensity, clinical malaria, immune response, plasmodic index, and to furthermore characterize a malaria vaccine trial site for potential malaria vaccines candidate testing, a study was conducted in Tensobtenga and Balonguen, two villages in Burkina Faso characterized by different malaria transmission levels. The study villages are located in a Sudan savanna area. Malaria transmission is seasonal and peaks in September in these villages. Tensobtenga and Balonguen are comparables in all aspects, except the presence of an artificial lake and wetlands in Tensobtenga. The mosquitoes sampling sites were randomly selected, taking into consideration the number of potential breeding sites, and the number of households in each village. Three times a week during 12 mo mosquitoes were collected by the Center for Disease Control and Prevention light traps in sentinel sites. To assess the infectivity the mosquitoes double ELISAs tests were performed on thoraces of female Anopheles gambiae s.l. (Giles) and Anopheles funestus. A total of 54,392 female Anopheles, representing 92.71% of the total mosquitoes, were collected. The peaks of aggressiveness because of either An. gambiae s.l. or An. funestus were observed in September in each of the villages. However, these peaks were lower in Balonguen compared with Tensobtenga. Malaria cumulative aggressiveness and transmission intensity because of both species peaked in September in each of the two villages, with lower values in Balonguen in comparison to Tensobtenga From February to May, malaria transmission intensity is negligible in Balonguen and <1 bite/person/mo is observed in Tensobtenga. These results have confirmed the marked seasonality of malaria transmission in the study area.

Substantial contribution of submicroscopical Plasmodium falciparum gametocyte carriage to the infectious reservoir in an area of seasonal transmission.

BACKGROUND: Man to mosquito transmission of malaria depends on the presence of the sexual stage parasites, gametocytes, that often circulate at low densities. Gametocyte densities below the microscopical threshold of detection may be sufficient to infect mosquitoes but the importance of submicroscopical gametocyte carriage in different transmission settings is unknown. METHODOLOGY/PRINCIPAL FINDINGS: Membrane feeding experiments were carried out on 80 children below 14 years of age at the end of the wet season in an area of seasonal malaria transmission in Burkina Faso. Gametocytes were quantified by microscopy and by Pfs25-based quantitative nucleic acid sequence-based amplification assay (QT-NASBA). The children's infectiousness was determined by membrane feeding experiments in which a venous blood sample was offered to locally reared Anopheles mosquitoes. Gametocytes were detected in 30.0% (24/80) of the children by microscopy compared to 91.6% (65/71) by QT-NASBA (p<0.001). We observed a strong association between QT-NASBA gametocyte density and infection rates (p = 0.007). Children with microscopically detectable gametocytes were more likely to be infectious (68.2% compared to 31.7% of carriers of submicroscopical gametocytes, p = 0.001), and on average infected more mosquitoes (13.2% compared to 2.3%, p<0.001). However, because of the high prevalence of submicroscopical gametocyte carriage in the study population, carriers of sub-microscopical gametocytes were responsible for 24.2% of the malaria transmission in this population. CONCLUSIONS/SIGNIFICANCE: Submicroscopical gametocyte carriage is common in an area of seasonal transmission in Burkina Faso and contributes substantially to the human infectious reservoir. Submicroscopical gametocyte carriage should therefore be considered when implementing interventions that aim to reduce malaria transmission.

Impact of slow-release Bacillus sphaericus granules on mosquito populations followed in a tropical urban environment.

A floating, slow-release, granular formulation of Bacillus sphaericus (Neide) was used to control mosquito larvae in two suburban areas of two tropical cities: Ouagadougou and Bobo-Dioulasso, Burkina Faso. A circular area of 2 km2, diameter 1,600 m, was treated in each city using a similar, smaller area 1 km away as an untreated control. Mosquito captures were made in houses in four concentric circles, from the periphery to the center; each circle was 50 m in width. Mosquitoes were captured in CDC light traps or from human landings. More than 95% of the mosquitoes were Culex quinquefasciatus (Say) (Diptera: Culicidae). The human landing catches provided twice as many mosquitoes as did the CDC traps/night/house. The treatments resulted in important reductions relative to the control area and to preintervention captures. The reduction was more prominent in the inner circle (up to 90%) than in the outer circle (50-70%), presumably because of the impact of immigrating mosquitoes from nontreated breeding sites around the intervention area. This effect was more pronounced for light trap catches than from human landings. The impact of treatment was also measured as the mean ratio of mosquito density in the two outer circles to that of the two inner circles. This ratio was approximately 1:1 before the intervention and reached 1:0.43 during the intervention. This comparison does not depend on the assumption that, in the absence of intervention, the mosquito population development in the two areas would have been identical, but does depend on the homogeneity of the intervention area. The study showed that it is possible to organize mosquito control in a tropical, urban environment by forming and rapidly training teams of young people to carry out the mosquito control mostly using a biopesticide that can be applied without any tools except an iron bar to lift lids on some cesspits.

Seasonal patterns of Plasmodium falciparum gametocyte prevalence and density in a rural population of Burkina Faso.

Gametocytes are the malaria parasite stages that secure the transmission from the human host to the mosquito. The identification of natural parameters that influence gametocyte carriage can contribute to a better understanding of the dynamics of the sexual stage parasites for transmission reducing strategies. A total of 3400 blood slide readings were done during four cross-sectional surveys (2002-2003) including all age groups to determine the effect of season on Plasmodium falciparum gametocytes in a seasonal malaria transmission area of Burkina Faso. Entomological data were collected to determine the malaria transmission intensity in relation to seasons. Transmission intensity was estimated by monthly EIRs, averaging 28 and 32 infective bites/person/month in the wet seasons of 2002 and 2003, respectively. The EIR in the dry seasons was below one infective bite/person/month. The gametocyte prevalence was significantly higher at the start and peak of the wet season compared to the dry season when corrected for asexual parasite density and age. Gametocyte density significantly increased during the wet season after correction for asexual parasite density and age. In this study, season appears to be an independent parameter that determines gametocyte prevalence and density and should be considered to be included in epidemiological studies on malaria transmission.

Children in Burkina Faso who are protected by insecticide-treated materials are able to clear drug-resistant parasites better than unprotected children.

BACKGROUND: It has been suggested that reducing exposure to malaria by vector control might impair the development of naturally acquired immunity to malaria. It is also thought that an individual's ability to clear drug-resistant malarial parasites after treatment is enhanced by acquired immunity. METHODS: To investigate the hypothesis that insecticide-treated materials may affect the acquisition of immunity to malaria, we compared the ability of children living in villages in which insecticide-treated curtains (ITCs) had been used for 6-8 years to clear resistant parasites after treatment with chloroquine (CQ) with that of children living in unprotected villages. RESULTS: A total of 1035 children aged 6-59 months with falciparum malaria were treated with CQ; 409 were subsequently identified as carrying parasites with the pfcrt-76T allele. More children from ITC villages cleared parasites harboring this allele than did children from non-ITC villages (34.1% vs. 24.0%; adjusted odds ratio [OR], 1.80 [95% confidence interval {CI}, 1.15-2.80]; P=.01). The difference in the clearance of parasites with the pfcrt-76T allele was seen in children aged 6-35 months (32.3% vs. 19.3%; adjusted OR, 2.34 [95% CI, 1.18-4.66]; P=.02) but not in older children (37.3% vs. 37.0%; adjusted OR, 1.09 [95% CI, 0.56-2.10]; P=.97). Rates of adequate clinical response among children carrying parasites with the pfcrt-76T allele were similar in ITC and non-ITC villages (75.1% vs. 68.6%; adjusted OR, 1.21 [95% CI, 0.61-2.39]; P=.58). CONCLUSION: Our data suggest that the children who were protected from malaria by ITCs acquired functional immunity more rapidly than did the control children.

Sustained use of insecticide-treated curtains is not associated with greater circulation of drug-resistant malaria parasites, or with higher risk of treatment failure among children with uncomplicated malaria in Burkina Faso.

The impact of vector control measures on the evolution of antimalarial drug resistance is an important issue for malaria control programs. We investigated whether the in vivo efficacy of chloroquine (CQ) in children aged 6-59 months with uncomplicated malaria differed in 9 villages that had benefited from long-term use of insecticide-treated curtains (ITCs) and in 9 nearby non-ITC villages. We also compared the prevalence of genetic markers of resistance to CQ and sulfadoxine-pyrimethamine (SP) between the two groups of villages. The study enrolled 1,035 children with uncomplicated malaria and 231 infected but asymptomatic children. After taking account of re-infections, the proportions of children who experienced clinical failure after treatment with CQ were 14% and 19% in ITC and non-ITC villages, respectively (OR = 0.68; 95% CI: 0.39, 1.18). Parasitologic failure was observed in 49% of children in ITC villages and 58% of children in non-ITC villages (OR = 0.71 95%CI: 0.44, 1.13). The proportion of symptomatic children who harbored parasites carrying the pfcrt-76T allele was 43% in ITC villages and 40% in non-ITC villages (OR = 1.09; 95%CI: 0.80, 1.50). The pfmdr1-86Y allele was detected in 31% and 29% of children in the two groups of villages (OR = 1.14; 95%CI: 0.75, 1.72). Triple mutations in the dhfr gene were observed in 12% of children in both groups. No double mutations in the dhps gene were observed. Similar results were observed in asymptomatic children. In this setting, ITC use was not associated with increased circulation of parasites resistant to standard antimalarial drugs, or with a greater risk of treatment failure among children less than 5 years of age.

Patterns of age-specific mortality in children in endemic areas of sub-Saharan Africa.

Understanding of the age- and season- dependence of malaria mortality is an important prerequisite for epidemiologic models of malaria immunity. However, most studies of malaria mortality have aggregated their results into broad age groups and across seasons, making it hard to predict the likely impact of interventions targeted at specific age groups of children. We present age-specific mortality rates for children aged < 15 years for the period of 2001-2005 in 7 demographic surveillance sites in areas of sub-Saharan Africa with stable endemic Plasmodium falciparum malaria. We use verbal autopsies (VAs) to estimate the proportion of deaths by age group due to malaria, and thus calculate malaria-specific mortality rates for each site, age-group, and month of the year. In all sites a substantial proportion of deaths (ranging from 20.1% in a Mozambican site to 46.2% in a site in Burkina Faso) were attributed to malaria. The overall age patterns of malaria mortality were similar in the different sites. Deaths in the youngest children (< 3 months old) were only rarely attributed to malaria, but in children over 1 year of age the proportion of deaths attributed to malaria was only weakly age-dependent. In most of the sites all-cause mortality rates peaked during the rainy season, but the strong seasonality in malaria transmission in these sites was not reflected in strong seasonality in the proportion of deaths attributed to malaria, except in the two sites in Burkina Faso. Improvement in the specificity of malaria verbal autopsies would make it easier to interpret the age and season patterns in such data.

Field evaluation of the efficacy and persistence of insect repellents DEET, IR3535, and KBR 3023 against Anopheles gambiae complex and other Afrotropical vector mosquitoes.

Synthetic insect repellents, IR3535 and KBR 3023 (also known as picaridin, or by the trade name Bayrepel, were tested in Burkina Faso against mosquito vectors of disease to compare their relative efficacy and persistence profiles to those of the 'gold standard' DEET. Collection of >49000 mosquitoes (approximately 95% belonging to the Anopheles gambiae complex) showed that after an exposure of 10h, KBR 3023 produced the highest protection against anophelines, followed by DEET, then IR3535. The response of aedines was more variable. By fitting a logistic plane model we estimated 95% effective dosages (ED95) for An. gambiae s.l., as well as a decay constant characterizing the exponential loss of repellent from the skin, with time. The ED95 values for DEET, IR3535, and KBR 3023 were 94.3, 212.4, and 81.8 microg/cm2 respectively. The decay constants were estimated at -0.241, -0.240, and -0.170 h(-1) respectively. The corresponding estimates of half-life were 2.9, 2.9, and 4.1h. Immunoenzymatic detection of the circumsporozoite protein (CSP) of Plasmodium falciparum in 842 An. gambiae s.l. showed that CSP-positive mosquitoes were equally frequent in treated and control subjects, indicating that the repellents could produce a reduction in the number of malaria infectious bites.

Evaluation of the sensitivity of Aedes aegypti and Anopheles gambiae complex mosquitoes to two insect repellents: DEET and KBR 3023.

We conducted laboratory tests to assess the sensitivity to the insect repellent 1-piperidinecarboxylic acid, 2-(2-hydroxyethyl)-, 1-methylpropylester (known as KBR 3023 or Picaridin, trade name Bayrepel) of West African strains of the yellow fever mosquito Aedes aegypti and of malaria vectors of the Anopheles gambiae complex, in comparison with the standard repellent N,N-diethyl-3-methyl-benzamide (DEET). Test mosquitoes were exposed according to a 'separate arms' protocol to logarithmic dose increments applied on one arm of human subjects to evaluate the relative potency, and the median effective dosages (ED50 and ED90). According to a logistic regression model fitted to the experimental data, the dose-response relationship for the two repellents was the same within each species, thus pooled ED values were assessed for each mosquito separately. The median ED of KBR 3023 and DEET was estimated at 0.78 (95% confidence limits (CI): 0.57-1.04) and at 0.018 microg/cm2 (0.004-0.052) for mosquitoes of the An. gambiae complex and Ae. aegypti, respectively. ED90 values were 125.6 (81.4-201.3) and 24.0 microg/cm2 (5.7-208.5) for An. gambiae s.l. and Ae. aegypti, respectively. The relative potency of KBR 3023 was not significantly different from that of DEET for An. gambiae s.l. (95% confidence limits 0.7-1.0), whereas in the case of Ae. aegypti it was with 95% probability 1.1-2.0 times more potent than DEET. On the basis of available evidence, KBR 3023 represents a promising alternative to DEET for personal protection against bites of these important vectors of disease in the Afrotropical region.