Surveillance for malaria outbreak on malaria-eliminating islands in Tafea Province, Vanuatu after Tropical Cyclone Pam in 2015.

The risk of malaria outbreak surfaced in Vanuatu after Tropical Cyclone (TC) Pam in March 2015. In June and July 2015 we conducted malariometric surveys on the islands of Tanna, Aneityum, and Erromango in Tafea Province, where malaria elimination had been targeted, to determine if malaria incidence had increased after TC Pam. No Plasmodium infection was detected by microscopy and PCR in 3009 survey participants. Only 6·3% (190/3007) of participants had fever. Spleen rates in children aged ⩽12 years from Aneityum and Tanna were low, at 3·6% (14/387) and 5·3% (27/510), respectively. Overall bed net use was high at 72·8% (2175/2986); however, a significantly higher (P < 0·001) proportion of participants from Aneityum (85·9%, 796/927) reported net use than those from Tanna (67·1%, 751/1119) and Erromango (66·8%, 628/940). A recent decrease in malaria incidence in Tafea Province through comprehensive intervention measures had reduced the indigenous parasite reservoir and limited the latter's potential to spur an outbreak after TC Pam. The path towards malaria elimination in Tafea Province was not adversely affected by TC Pam.

Population structure and gene flow of Anopheles farauti s.s. (Diptera: Culicidae) among ten sites on five islands of Vanuatu: implications for malaria control.

The Anopheles punctulatus (Diptera: Culicidae) group is the main vector for malaria and Bancroftian filariasis in Vanuatu. Anopheles larvae were collected from 10 localities on five islands of Vanuatu during the 2004 dry season for species identification as well as for estimating population structure and gene flow within and among islands. Species identification was determined using polymerase chain reaction-restriction fragment length polymorphism analysis of the internal transcribed spacer 2 region. Population structure and gene flow were examined by sequencing a portion of the ND4/ND5 region of the mitochondrial genome. Only one species of the An. punctulatus group, An. farauti s.s., was identified, consistent with previous studies in Vanuatu. A nonrandom distribution of An. farauti s.s. lineages was observed with one cosmopolitan lineage shared by eight sites on all five islands and a preponderance of island-specific lineages (36/40), indicating the introduction of a single main lineage into Vanuatu followed by dispersal, diversification, and limited lineage exchange between islands. Network analysis suggests a possible second introduction of An. farauti s.s. into the northern islands of Gaua and Malekula. Gene flow was high on three of the five islands, whereas Tanna and Santo have significant population structure. Among islands, gene flow was limited, indicating active mosquito dispersal only over short distances and a paucity of passive human-mediated dispersal over long distances. Minimal risk of active dispersal among these islands indicates that vector control can be effectively initiated at the island level within the archipelago of Vanuatu.

Genetic diversity and gene flow of humans, Plasmodium falciparum, and Anopheles farauti s.s. of Vanuatu: inferred malaria dispersal and implications for malaria control.

A comparison of the patterns of gene flow within and between islands and the genetic diversities of the three species required for malaria transmission (humans, Plasmodium falciparum, and Anopheles farauti s.s.) within the model island system of Vanuatu, shows that the active dispersal of An. farauti s.s. is responsible for within island movement of parasites. In contrast, since both P. falciparum and An. farauti s.s. populations are largely restricted to islands, movement of parasites between islands is likely due to human transport. Thus, control of vectors is crucial for controlling malaria within islands, while control of human movement is essential to control malaria transmission across the archipelago.

Microfilarial periodicity of Wuchereria bancrofti in Vanuatu.

A study on the relationship between the microfilarial periodicity of Wuchereria bancrofti and vector biting activity was carried out in Penama province, Vanuatu from February to April 1999, to enable the design of a more efficient strategy to control filariasis transmission. The microfilarial periodicities of 22 W. bancrofti antigen-positive volunteers were studied. Microfilariae (mf) were counted every hour for 24 h for 6 volunteers and every hour for 12 h (from 18:00 to 06:00) for 16 volunteers. At the same time as the preparation of mf test slides, indoor human landing catches of the vector mosquito, Anopheles farauti, were conducted to assess the vector biting activity. The time of peak microfilaraemia was 01:32 and the microfilarial periodicity index was 112.3, confirming the nocturnal periodicity of Wuchereria bancrofti in Vanuatu. Nearly all (98.5%) of the mf appeared during the time periods when A. farauti were collected. The timing of vector biting activity corresponded to the time of mf circulation.

Progress towards, and challenges for, the elimination of filariasis from Pacific-island communities.

The Pacific Programme for the Elimination of Lymphatic Filariasis (PacELF) - the first regional campaign to attempt to eliminate filariasis as a public-health problem - is using five, annual, mass drug administrations (MDA) of diethylcarbamazine (DEC) plus albendazole to stop transmission. In 2001, nine countries and territories covered by the programme had begun annual MDA campaigns, with population treatment coverages ranging from 52% to 95%. By the end of 2002, it is anticipated that 11 countries/territories will have begun such MDA campaigns. Even with high MDA coverage, the efficiency of Aedes polynesiensis as a vector of Wuchereria bancrofti may limit the effectiveness of the elimination campaigns in some countries. In areas of limited MDA coverage, additional strategies, such as vector control (as a adjunct to the MDA), or alternative approaches, such as the use of DEC-fortified salt, may be necessary to stop transmission.

Malaria eradication on islands.

BACKGROUND: To be successful, a malaria control programme needs to be tailored to the local epidemiological characteristics. Vanuatu consists of 80 inhabited islands in the Southwest Pacific, with hypoendemic and mesoendemic malaria and suitable conditions for sustained parasite elimination. We aimed to assess whether malaria can be eliminated on isolated islands. METHODS: Weekly mass drug administration of chloroquine, pyrimethamine/sulfadoxine (Fansidar), and primaquine was carried out on the entire population of 718 inhabitants of Aneityum island for 9 weeks in 1991 before the onset of the rainy season. Simultaneously with the administration of drugs, permethrin-impregnated bednets were distributed to the entire population. Larvivorous fish were also introduced into several identified breeding sites of Anopheles farauti. Periodic malariometric monitoring has continued for the past 9 years. Two additional islands of Vanuatu, one with and one without malaria transmission, have been monitored for comparison. FINDINGS: High community involvement as measured by drug compliance (88.3%) and bednet provision (0.94 nets per villager) has resulted in sustained interruption of malaria transmission in Aneityum. The surveys showed complete absence of Plasmodium falciparum after mass drug administration, and P. vivax disappeared from 1996 onwards, with the exception of two instances of imported infections (one mixed infection in 1993 and one P. vivax infection in 1999). INTERPRETATION: Malaria can be eliminated on isolated islands with well-adapted short-term mass drug administration and sustained vector control if there is a high degree of community participation.

Dengue surveillance in the Pacific Islands.

Adequate monitoring of dengue activity can be achieved using a combination of mosquito vector surveillance, fever surveillance, sentinel clinicians and laboratory screening. An apparent increase in fever cases or clinically suspected DF should prompt a careful clinical and laboratory investigation. If an outbreak of dengue is confirmed, health authorities will need to implement emergency community-wide control strategies. Laboratories will quickly feel the burden of clinical monitoring of cases admitted with DHF/DSS. Surveillance can change to clinical case definitions as health workers become familiar with the presenting features of DF and DHF/DSS. Criteria for hospital referral and admission must be well understood. Routine laboratory and sentinel surveillance may resume as the epidemic wanes, and should then continue indefinitely to monitor any resurgence of dengue activity.

Proguanil disposition and toxicity in malaria patients from Vanuatu with high frequencies of CYP2C19 mutations.

The increasing resistance of falciparum malaria to common antimalarial drugs has renewed interest in the compound proguanil normally metabolized to cycloguanil, a strong dihydrofolate reductase inhibitor, via the cytochrome P450 isozyme CYP2C19. The relationship between CYP2C19 genotypes and proguanil metabolism was therefore studied in 100 uncomplicated malaria patients on Malakula island in Vanuatu, where a CYP2C19-related poor metabolizer genotype status was known to be frequent. The patients (median age, 7 years) with Plasmodium falciparum or P. vivax infections, received proguanil treatment for 3 days in daily doses corresponding to adult doses of 300-500 mg. Capillary blood samples were collected on filter paper for determining both human CYP2C19 mutations by polymerase chain reaction and mutation-specific restriction enzyme digestion and blood concentrations of proguanil and its metabolites by high-performance liquid chromatography. The frequencies of the defective alleles, CYP2C19*2 and CYP2C19*3, were 0.57 and 0.25, respectively. The patients were genotyped as 68 CYP2C19-related poor metabolizers and 32 extensive metabolizers. Proguanil concentrations were higher and cycloguanil and 4-chlorophenylbiguanide concentrations were lower in poor compared to extensive metabolizers. Among the extensive metabolizers, 27 were heterozygous and five were homozygous for unmutated alleles. The tendency of an intermediate degree of proguanil metabolism in heterozygous extensive metabolizers as compared to homozygous extensive metabolizers and poor metabolizers suggests the trend towards the existence of a gene dose effect. Mild adverse events (mainly gastro-intestinal symptoms) were often reported and positively correlated with proguanil concentrations. The incidence was, however, similar in poor and extensive metabolizers. In conclusion, our data demonstrate an association between CYP2C19 mutations and poor metabolism of proguanil.

Malaria epidemiology, glucose 6-phosphate dehydrogenase deficiency and human settlement in the Vanuatu Archipelago.

Vanuatu is located at the southeast margin of the malarious band extending from southeast Asia to eastern Melanesia. We analysed the malaria situation on different islands of Vanuatu, using passive case detection and malariometric survey data from 1985 to 1992, i.e. after the DDT residual programme ceased and before the impregnated bed-nets programme started on a larger scale. Malaria was mainly hypo-mesoendemic but with hyperendemic spots in certain years and on some islands. The transmission was generally more intense in the northern islands than in the south. In the late 1980s, annual parasite incidence per one thousand population (API) was around 180. The overall parasite rate was 11.9% with Plasmodium falciparum, P. vivax and P. malariae rate of 5.2, 6.7, and 0.1%, respectively. There was a seasonal fluctuation of P. falciparum incidence, whereas the P. vivax incidence was rather stable. Vivax malaria was confined to children less than 10 years old, while the intense in the northern islands than in the south. In the late 1980s, annual parasite incidence per one thousand population (API) was around 180. The overall parasite rate was 11.9% with Plasmodium falciparum, P. vivax and P. malariae rate of 5.2, 6.7, and 0.1%, respectively. There was a seasonal fluctuation of P. falciparum incidence, whereas the P. vivax incidence prevalence of P. falciparum only changed moderately with age. The mean rate of glucose 6-phosphate dehydrogenase (G6PD) deficiency among male subjects was in 7.4% but with a wide variation of 0-14.3% on different islands. A positive rank-order correlation was found between malaria incidence and G6PD deficiency rate on the different islands. A reasonable hypothesis is that malaria was introduced to the islands with the first human settlement 4000 years ago, with a geographical malaria distribution similar to the present situation. Different malaria endemicities possibly then selected different prevalences of G6PD deficiency over many generations.