Health policy impacts on malaria transmission in Costa Rica

Community-serving research addressing climate change impacts on vector-borne diseases

The impacts of climate change on vector-borne diseases are uneven across human populations. This pattern reflects the effect of changing environments on the biology of transmission, which is also modulated by social and other inequities. These disparities are also linked to research outcomes that could be translated into tools for transmission reduction, but are not necessarily actionable in the communities where transmission occurs. The transmission of vector-borne diseases could be averted by developing research that is both hypothesis-driven and community-serving for populations affected by climate change, where local communities interact as equal partners with scientists, developing and implementing research projects with the aim of improving community health. In this Personal View, we share five principles that have guided our research practice to serve the needs of communities affected by vector-borne diseases.

Spatiotemporal Analysis of Malaria Transmission in the Autonomous Indigenous Regions of Panama, Central America, 2015-2022

Despite ongoing efforts for elimination, malaria continues to be a major public health problem in the Republic of Panama. For effective elimination, it is key that malaria foci and areas of high transmission are identified in a timely manner. Here, we study malaria transmission records for the 2015-2022 period, a time when cases have increased by a factor of ten. Using several methods to study spatial and spatiotemporal malaria confirmed case clusters at the level of localities, including LISA and scan, we found that cases are clustered across indigenous villages located within the autonomous indigenous regions of Ngäbe-Buglé, Guna Yala, and Embera, with the latter on the eastern border of Panama (with Colombia). We discuss the different factors that might be shaping the marked increase in malaria transmission associated with these clusters, which include an inflow of malaria-exposed migrating populations hoping to reach the USA, insufficient health services, and the lack of culturally sensitive actionable tools to reduce malaria exposure among the ethnically diverse and impoverished indigenous populations of Panama.

Anopheles albimanus (Diptera: Culicidae) Ensemble Distribution Modeling: Applications for Malaria Elimination

Simple Summary

Costa Rica is near malaria elimination. However, sporadic outbreaks still occur, and while control strategies have been focused on delivering efficient treatments for infected patients, an open question is whether control measures targeting the dominant vector, Anopheles albimanus, are appropriately designed given their ecology and distribution. Here, we illustrate the use of an ensemble species distribution model (SDM) as a tool to assess the potential exposure to An. albimanus in palm and pineapple plantations, and to also assess the potential involvement of this mosquito vector in transmission foci where entomological surveillance is not feasible. We found that both oil palm and pineapple plantations are very likely to harbor An. albimanus. By contrast, environments at the Crucitas open-pit gold mine, the epicenter of malaria transmission in 2018 and 2019, have low suitability for this mosquito species. Our results suggest that medium to high resolution SDMs can be used to plan vector control activities. Finally, we discuss the high suitability of oil palm and pineapple plantations for An. albimanus in reference to recently developed social science theory about the Plantationocene.

Abstract

In the absence of entomological information, tools for predicting Anopheles spp. presence can help evaluate the entomological risk of malaria transmission. Here, we illustrate how species distribution models (SDM) could quantify potential dominant vector species presence in malaria elimination settings. We fitted a 250 m resolution ensemble SDM for Anopheles albimanus Wiedemann. The ensemble SDM included predictions based on seven different algorithms, 110 occurrence records and 70 model projections. SDM covariates included nine environmental variables that were selected based on their importance from an original set of 28 layers that included remotely and spatially interpolated locally measured variables for the land surface of Costa Rica. Goodness of fit for the ensemble SDM was very high, with a minimum AUC of 0.79. We used the resulting ensemble SDM to evaluate differences in habitat suitability (HS) between commercial plantations and surrounding landscapes, finding a higher HS in pineapple and oil palm plantations, suggestive of An. albimanus presence, than in surrounding landscapes. The ensemble SDM suggested a low HS for An. albimanus at the presumed epicenter of malaria transmission during 2018–2019 in Costa Rica, yet this vector was likely present at the two main towns also affected by the epidemic. Our results illustrate how ensemble SDMs in malaria elimination settings can provide information that could help to improve vector surveillance and control.

Plasmodium vivax Genetic Diversity in Panama: Challenges for Malaria Elimination in Mesoamerica

Panama and all nations within the Mesoamerican region have committed to eliminate malaria within this decade. With more than 90% of the malaria cases in this region caused by Plasmodium vivax, an efficient national/regional elimination plan must include a comprehensive study of this parasite's genetic diversity. Here, we retrospectively analyzed P. vivax genetic diversity in autochthonous and imported field isolates collected in different endemic regions in Panama from 2007 to 2020, using highly polymorphic markers (csp, msp-1, and msp-3α). We did the analysis using molecular techniques that are cost-effective for malaria molecular surveillance within Mesoamerica. Thus, we used molecular analyses that are feasible for malaria molecular surveillance within the region, and that can provide useful information for policy and decision making about malaria elimination. We also evaluated if haplotypes established by combining the genotypes found in these genes were associated with relevant epidemiological variables and showed structure across the transmission foci that have been observed in Panama. Ten different haplotypes were identified, some of them strongly associated with geographical origin, age, and collection year. Phylogenetic analysis of csp (central repeat domain) revealed that both major variant types (vk210 and vk247) were circulating in Panama. Variant vk247 was restricted to the eastern endemic regions, while vk210 was predominant (77.3%) and widespread, displaying higher diversity (14 alleles) and geographically biased alleles. The regional implications of these molecular findings for the control of P. vivax malaria to achieve elimination across Mesoamerica are discussed.

Towards the elimination of Plasmodium vivax malaria: Implementing the radical cure

In this review for the Vivax malaria collection, Kamala Thriemer and colleagues explore efforts to eliminate P. vivax malaria.

Modeling the association between Aedes aegypti ovitrap egg counts, multi-scale remotely sensed environmental data and arboviral cases at Puntarenas, Costa Rica (2017–2018)

Problems with vector surveillance are a major barrier for the effective control of vector-borne disease transmission through Latin America. Here, we present results from a 80-week longitudinal study where Aedes aegypti (L.) (Diptera: Culicidae) ovitraps were monitored weekly at 92 locations in Puntarenas, a coastal city in Costa Rica with syndemic Zika, chikungunya and dengue transmission. We used separate models to investigate the association of either Ae. aegypti-borne arboviral cases or Ae. aegypti egg counts with remotely sensed environmental variables. We also evaluated whether Ae. aegypti-borne arboviral cases were associated with Ae. aegypti egg counts. Using cross-correlation and time series modeling, we found that arboviral cases were not significantly associated with Ae. aegypti egg counts. Through model selection we found that cases had a non-linear response to multi-scale (1-km and 30-m resolution) measurements of temperature standard deviation (SD) with a lag of up to 4 weeks, while simultaneously increasing with finely-grained NDVI (30-m resolution). Meanwhile, median ovitrap Ae. aegypti egg counts increased, and respectively decreased, with temperature SD (1-km resolution) and EVI (30-m resolution) with a lag of 6 weeks. A synchrony analysis showed that egg counts had a travelling wave pattern, with synchrony showing cyclic changes with distance, a pattern not observed in remotely sensed data with 30-m and 10-m resolution. Spatially, using generalized additive models, we found that eggs were more abundant at locations with higher temperatures and where EVI was leptokurtic during the study period. Our results suggest that, in Puntarenas, remotely sensed environmental variables are associated with both Ae. aegypti-borne arbovirus transmission and Ae. aegypti egg counts from ovitraps.

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We sampled Ae. aegypti eggs using ovitraps for 80 weeks in Puntarenas, Costa Rica.

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We were able to correlate Ae. aegypti egg-counts and arboviral cases with remotely sensed data.

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Egg counts and arboviral cases were correlated with temperature and vegetation indices.

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Arboviral cases were not associated with egg counts.

Spatial and Temporal Analysis of Plasmodium knowlesi Infection in Peninsular Malaysia, 2011 to 2018

The life-threatening zoonotic malaria cases caused by Plasmodium knowlesi in Malaysia has recently been reported to be the highest among all malaria cases; however, previous studies have mainly focused on the transmission of P. knowlesi in Malaysian Borneo (East Malaysia). This study aimed to describe the transmission patterns of P. knowlesi infection in Peninsular Malaysia (West Malaysia). The spatial distribution of P. knowlesi was mapped across Peninsular Malaysia using Geographic Information System techniques. Local indicators of spatial associations were used to evaluate spatial patterns of P. knowlesi incidence. Seasonal autoregressive integrated moving average models were utilized to analyze the monthly incidence of knowlesi malaria in the hotspot region from 2012 to 2017 and to forecast subsequent incidence in 2018. Spatial analysis revealed that hotspots were clustered in the central-northern region of Peninsular Malaysia. Time series analysis revealed the strong seasonality of transmission from January to March. This study provides fundamental information on the spatial distribution and temporal dynamic of P. knowlesi in Peninsular Malaysia from 2011 to 2018. Current control policy should consider different strategies to prevent the transmission of both human and zoonotic malaria, particularly in the hotspot region, to ensure a successful elimination of malaria in the future.

Plasmodium falciparum Genetic Diversity in Panamá Based on glurp, msp-1 and msp-2 Genes: Implications for Malaria Elimination in Mesoamerica

Panamá, together with all the nations in Mesoamerica, has committed to eliminate malaria from the region by 2020. As these countries approach malaria elimination and local transmission decreases, an active molecular surveillance to identify genotypes circulating along the border areas is particularly needed to accurately infer infection origin, drug resistance and disease propagation patterns in the region. This study evaluated the genetic diversity and allele frequencies of msp-1, msp-2 and glurp genes using different molecular analyses (nested PCR, PCR-restriction fragment length polymorphism (RFLP) and sequencing) from 106 autochthonous and imported P. falciparum isolates collected from different endemic areas in Panamá between 2003 and 2019. We also explored if P. falciparum genotypes assessed with these molecular markers were associated with relevant malaria epidemiological parameters using a multiple correspondence analysis. A strong association of certain local haplotypes with their geographic distribution in endemic areas, but also with parasite load and presence of gametocytes, was evidenced. Few multiclonal infections and low genetic diversity among locally transmitted P. falciparum samples were detected, consequent with the low transmission intensity of this parasite in Panamá, a pattern likely to be extended across Mesoamerica. In addition, several imported cases were genetically dissimilar to local infections and representative of more diverse extra-continental lineages.

Long-term transmission patterns and public health policies leading to malaria elimination in Panamá

Background

The present study provides a countrywide perspective of the malaria situation in Panamá over a long-term framework, with the purpose of identifying historical malaria resurgence events and their potential causes.

Methods

A descriptive-ecological study was conducted by analysing demographic and epidemiological annual malaria time series data in Panamá (1884–2019) using several data sources. Malaria intensity indicators were calculated during the study period. The effects of El Niño Southern Oscillation on malaria transmission were also analysed using a retrospective analysis of malaria cases between 1957 and 2019.

Results

Several factors were identified responsible for malaria resurgence in Panamá, mostly related with Malaria Control Programme weakening. During the past 20 years (2000–2019) malaria has progressively increased in prevalence within indigenous settlements, with a predominance of male cases and a high proportion (15% of total cases) in children less than 5 years old. During this period, a significant and increasing proportion of the Plasmodium falciparum cases were imported. Retrospective analysis (1957–2019) evidenced that ENSO had a significant impact on malaria transmission dynamics in Panamá.

Conclusions

Data analysis confirmed that although authorities have been successful in focalizing malaria transmission in the country, there are still neglected issues to be solved and important intercultural barriers that need to be addressed in order to achieve elimination of the disease by 2022. This information will be useful for targeting strategies by the National Malaria Elimination Programme.

Malaria Elimination in Costa Rica: Changes in Treatment and Mass Drug Administration

Costa Rica is a candidate to eliminate malaria by 2020. The remaining malaria transmission hotspots are located within the Huétar Norte Region (HNR), where 90% of the country's 147 malaria cases have occurred since 2016, following a 33-month period without transmission. Here, we examine changes in transmission with the implementation of a supervised seven-day chloroquine and primaquine treatment (7DCPT). We also evaluate the impact of a focal mass drug administration (MDA) in January 2019 at Boca Arenal, the town in HNR reporting the greatest local transmission. We found that the change to a seven-day treatment protocol, from the prior five-day program, was associated with a 98% reduction in malaria transmission. The MDA helped to reduce transmission, keeping the basic reproduction number, R_T, significantly below 1, for at least four months. However, following new imported cases from Nicaragua, autochthonous transmission resumed. Our results highlight the importance of appropriate treatment delivery to reduce malaria transmission, and the challenge that highly mobile populations, if their malaria is not treated, pose to regional elimination efforts in Mesoamerica and México.