Antimalarial drug resistance is one of the biggest threats to the control and eventual elimination of malaria. Resistance is confirmed to all currently available antimalarials, including the most pivotal group of antimalarials, the artemisinins. Artemisinin resistance and/or Kelch13 mutations associated with artemisinin resistance in P. falciparum has now been detected in seven countries across South-East Asia. This includes India, from where global spread is considered inevitable.

Mutations associated with resistance have also been detected (over 5% prevalence) in Guyana, Papua New Guinea and Rwanda. Areas of the lowest malaria transmission intensity, like South Africa, are at the highest risk of the spread or emergence of antimalarial drug resistance. In these low transmission areas, the incidence of infection is too infrequent for the development of partial malaria immunity needed to compensate for failing treatments, and drug pressure is increased as the majority of infections are symptomatic and require treatment. 

Areas of the lowest intensity transmission most need an efficient, up-to-date and effective targeted information system, which we refer to in this pilot study as “Smart Surveillance 4 Elimination”, in order to rapidly detect and respond to emerging drug resistance, before it increases malaria transmission, morbidity and mortality and derails elimination efforts.

To improve malaria treatment and advance malaria elimination in South Africa and beyond.

• To develop and pilot an approach for real-time mapping of antimalarial drug resistance using novel technologies to scale up assays for molecular markers of antimalarial resistance (assayed from positive malaria rapid diagnostic tests) and integrate these data with data from individual malaria case notifications (from active and passive detection)
• To identify the foci that require more intensive investigation and additional interventions to further reduce malaria transmission
• To inform effective targeting of single low dose primaquine treatment to block malaria transmission
• To inform any changes needed to malaria treatment policy

• To work with local stakeholders to a) identify and address obstacles to prompt accurate notification of malaria cases and submission of positive rapid diagnostic tests (RDTs) to the National Institute of Communicable Diseases (NICD), b) to facilitate optimal data sharing to inform prompt response by provincial, national and regional malaria control programmes, and c) ensure wider utility and sustainability of the refined WWARN Smart Surveillance 4 Elimination platform
• To scale up polymerase chain reaction assays using MassARRAY systems to determine the detect molecular markers of artemisinin and lumefantrine resistance from each malaria positive rapid diagnostic test, with central data systems to allow rapid curation of these data
• To adapt the WWARN Smart Surveillance platform into the WWARN Smart Surveillance 4 Elimination platform to fit geospatial data from Mpumalanga, SA and expand to include a) malaria notification data and b) markers of both artemisinin and lumefantrine resistance

The field work of this project is now complete, and analysis is ongoing. We anticipate a final report by approximately Q3 2020

The project has been done in collaboration with: 

• South African National Institute for Communicable Diseases
• Mpumalanga and KwaZulu Natal Provincial Malaria Elimination Programmes
• South African Department of Health
• Clinton Health Access Initiative
• Humana People to People in South Africa
• WWARN, University of Oxford

Use our kelch markers toolkit which recommends minimal criteria for reporting Plasmodium falciparum kelch13 (pfkelch13) markers for reporting artemisinin drug resistance.