Herd protection against Plasmodium falciparum infections conferred by mass antimalarial drug administrations and the implications for malaria elimination

Introduction: All nations of the Greater Mekong Subregion have committed to elimination of malaria by the year 2030. Elimination efforts rely on increasing access to diagnosis and treatment. However, asymptomatic infections pose a major challenge for these efforts. One approach towards eliminating asymptomatic reservoirs is targeted mass antimalarial drug administration (MDA). Here we present a fine scale spatiotemporal analysis of malaria incidence and prevalence in villages undergoing MDA. Methods: Four villages along the Myanmar-Thailand border were selected for a MDA pilot study based on clinical records and prevalence surveys. Passive detection of clinical episodes was facilitated through community based malaria clinics in each village. All villagers were screened using venous blood and ultra-sensitive qPCR (uPCR) for detection of parasites at baseline and every subsequent 3 months until month 18 (M18). A final screening was done at M24. MDAs were conducted on M0, M1 and M2 in two villages and on M9, M10, M11 in the remaining two villages. Which villages received early or deferred MDA was decided using restricted randomization. MDA participation, clinical episodes and uPCR detected infections were mapped to participant houses. Scan statistics were used to test for clusters of malaria episodes, malaria infections and non-adherence to MDA. Mixed effects regressions were used to test for risk factors for clinical episodes after MDA. Results: Neighborhood level MDA adherence was a major predictor for clinical episodes of malaria post-MDA, suggesting a strong herd effect. Each village had a cluster of P. falciparum infections at M0. After M0, there were no clusters of uPCR detectable P. falciparum infections. Clinical episodes of P. falciparum occurred in one village only which had a cluster of non-adherence to MDA and a high mosquito vector human biting rate. Individuals with subclinical P. falciparum infections were more likely to have subsequent clinical episodes than individuals who had no subclinical infections. Individuals who lived in a house with someone who had a clinical episode were more likely to also have a clinical episode subsequently than individuals residing in a house free of P. falciparum infections. Conclusion: To our knowledge this is the first study to show a herd effect from MDA for malaria. These data and results have significance for spatial targeting of interventions for malaria elimination. Clusters of non-adherence to MDA participation can lead to failed elimination if they occur among individuals with asymptomatic infections and given sufficient mosquito vector exposure. Community participation, which can be facilitated through community engagement, is key to MDA success.