Review

The last man standing is the most resistant: eliminating artemisinin-resistant malaria in Cambodia

Richard J Maude^1,2 , Wirichada Pontavornpinyo¹ , Sompob Saralamba¹ , Ricardo Aguas³ , Shunmay Yeung^1,4 , Arjen M Dondorp^1,2 , Nicholas PJ Day^1,2 , Nicholas J White^1,2 and Lisa J White¹

¹  Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Rajthevee, Bangkok 10400, Thailand

²  Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, Unversity of Oxford, Oxford, UK

³  Instituto Gulbenkian de Ciência, Oeiras, Portugal

⁴  Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK

author email corresponding author email

Malaria Journal 2009, 8:31doi:10.1186/1475-2875-8-31

Published:	20 February 2009

Abstract

Background

Artemisinin combination therapy (ACT) is now the recommended first-line treatment for falciparum malaria throughout the world. Initiatives to eliminate malaria are critically dependent on its efficacy. There is recent worrying evidence that artemisinin resistance has arisen on the Thai-Cambodian border. Urgent containment interventions are planned and about to be executed. Mathematical modeling approaches to intervention design are now integrated into the field of malaria epidemiology and control. The use of such an approach to investigate the likely effectiveness of different containment measures with the ultimate aim of eliminating artemisinin-resistant malaria is described.

Methods

A population dynamic mathematical modeling framework was developed to explore the relative effectiveness of a variety of containment interventions in eliminating artemisinin-resistant malaria in western Cambodia.

Results

The most effective intervention to eliminate artemisinin-resistant malaria was a switch of treatment from artemisinin monotherapy to ACT (mean time to elimination 3.42 years (95% CI 3.32–3.60 years). However, with this approach it is predicted that elimination of artemisinin-resistant malaria using ACT can be achieved only by elimination of all malaria. This is because the various forms of ACT are more effective against infections with artemisinin-sensitive parasites, leaving the more resistant infections as an increasing proportion of the dwindling parasite population.

Conclusion

Containment of artemisinin-resistant malaria can be achieved by elimination of malaria from western Cambodia using ACT. The "last man standing" is the most resistant and thus this strategy must be sustained until elimination is truly achieved.