Assessment of the risk posed to Singapore by the emergence of artemisinin-resistant malaria in the Greater Mekong Subregion
DOI:
https://doi.org/10.5365/wpsar.2018.9.2.011Abstract
Objective: To assess the public health risk to Singapore posed by the emergence of artemisinin-resistant (ART-R) malaria in the Greater Mekong Subregion (GMS).
Methods: We assessed the likelihood of importation of drug-resistant malaria into Singapore and the impact on public health of its subsequent secondary spread in Singapore. Literature on the epidemiology and contextual factors associated with ART-R malaria was reviewed. The epidemiology of malaria cases in Singapore was analysed. The vulnerability and receptivity of Singapore were examined, including the connectivity with countries reporting ART-R malaria, as well as the preparedness of Singaporean health authorities. Sources of information include international journals, World Health Organization guidelines, data from the Singapore Ministry of Health and National Public Health Laboratory of the National Centre for Infectious Diseases, and the International Air Transport Association.
Results: The importation of ART-R malaria into Singapore is possible given the close proximity and significant travel volume between Singapore and the GMS countries reporting artemisinin resistance. Singapore’s vulnerability is further enhanced by the presence of foreign workers from neighbouring endemic countries. Nonetheless, the overall likelihood of such an event is low based on the rarity and decreasing trend of imported malaria incidence.
With the presence of Anopheles vectors in Singapore, imported cases of drug-resistant malaria could cause secondary transmission. Nevertheless, the risk of sustained spread is likely to be mitigated by the comprehensive surveillance and control system in place for both infected vectors and human cases.
Discussion: This risk assessment highlights the need for a continued high degree of vigilance of ART-R malaria locally and globally to minimize the risk and public health impact of drug-resistant malaria in Singapore.
References
World Malaria Report 2017. Geneva, World Health Organization, 2017 (http://apps.who.int/iris/bitstream/handle/10665/259492/9789241565523-eng.pdf;jsessionid=A9E049B0F2325477C96E3563D189FD1A?sequence=1, accessed 30 April 2018).
White NJ et al. Malaria. Lancet, 2014, 383(9918) : 722-735. doi:10.1016/S0140-6736(13)60024-0 pmid : 23953767
Worldwide antimalarial resistance network. (http://www.wwarn.org/, accessed 29 December 2017).
Noedl H et al. Evidence of artemisinin-resistant malaria in western Cambodia. New England Journal of Medicine, 2008, 359(24):2619–2620. doi: 10.1056/NEJMc0805011 pmid: 19064625
Status report on artemisinin and artemisinin-based combination therapy resistance. Geneva, World Health Organization, 2017 (http://www.who.int/malaria/publications/atoz/artemisinin-resistance-april2017/en/, accessed 30 April 2018).
Rapid risk assessment of acute public health events. Geneva, World Health Organization, 2012 (http://www.who.int/csr/resources/publications/HSE_GAR_ARO_2012_1/en/, accessed 30 April 2018).
Communicable Diseases Surveillance in Singapore, 2005-2015. Singapore Ministry of Health, 2016 (https://www.moh.gov.sg/content/moh_web/home/Publications/Reports/2016.html, accessed 18 August 2017)
Bogoch II et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 West African outbreak. Lancet, 2015, 3, 385(9962):29–35. doi:10.1016/S0140-6736(14)61828-6 pmid:25458732
Ariey et al. A molecular marker of artemisinin-resistant Plasmodium falciparum malaria. Nature, 2014, 505(7481):50-55. doi:10.1038/nature12876. pmid: 24352242
Fact sheet on malaria. Geneva, World Health Organization, 2018. (http://www.who.int/en/news-room/fact-sheets/detail/malaria, accessed 30 April 2018)
Guidelines for the treatment of malaria, 3rd edition. Geneva, World Health Organization, 2015. (http://apps.who.int/iris/bitstream/10665/162441/1/9789241549127_eng.pdf?ua=1&ua=1, accessed 30 April 2018)
Artemisinin and artemisinin-based combination therapy resistance. Geneva, World Health Organization, 2017. http://apps.who.int/iris/bitstream/10665/255213/1/WHO-HTM-GMP-2017.9-eng.pdf?ua=1, accessed 30 April 2018)
Payne D. Spread of chloroquine resistance in Plasmodium falciparum. Parasitology Today, 1987, 3 (8): 241–246. pmid:15462966
Thu AM et al. Combating multidrug-resistant Plasmodium falciparum malaria. The FEBS Journal, 2017, 284(16):2569-2578. doi: 10.1111/febs.14127. pmid:28580606
Dondorp AM et al. Artemisinin resistance in Plasmodium falciparum malaria. New England Journal of Medicine, 2009, 361(5):455–467. doi: 10.1056/NEJMoa0808859 pmid:19641202
Amato R et al. Origins of the current outbreak of multidrug-resistant malaria in southeast Asia: a retrospective genetic study. Lancet Infectious Diseases, 2018, 18(3):337-345. doi: 10.1016/S1473-3099(18)30068-9 pmid: 29398391
Dondorp AM et al. The threat of artemisinin-resistant malaria. New England Journal of Medicine, 2011, 365(12):1073–1075. doi: 10.1056/NEJMp1108322 pmid: 21992120
Rathod PK et al. Variations in frequencies of drug resistance in Plasmodium falciparum. Proceedings of the National Academy of Sciences of the United States of America, 1997, 94(17):9389-9393 pmid: 9256492
Goh KT. Eradication of malaria from Singapore. Singapore Medical Journal, 1983, 24(5):255-268.
Mosquitoes & mosquito borne diseases. National Environmental Agency, Singapore. (http://www.nea.gov.sg/docs/default-source/public-health/vector-control/section-a---mosquitoes-amp-mosquito-borne-diseases-pdf-1-41-mb-.pdf, accessed 30 April 2018)
Lin YJ et al. Epidemiology of Malaria in Singapore, 2008-2015. Epidemiological News Bulletin, 2016; 42(2): 49-54.
Smith et al. A sticky situation: the unexpected stability of malaria elimination. Philosophical Transactions of The Royal Society B, 2013, 368(1623):20120145. doi: 10.1098/rstb.2012.0145. pmid: 23798693
Lee YCA et al. Epidemiological characteristics of imported and locally-acquired malaria in Singapore. Annals Academy of Medicine Singapore, 2009, 38(10): 840-849. pmid: 19890574
Strategy for malaria elimination in the GMS (2015–2030). Geneva, World Health Organization, 2015
(http://www.wpro.who.int/mvp/documents/strat_mal_elim_gms/en/, accessed 30 April 2018).
New global fund grant aims for malaria elimination in the Mekong. The Global Fund, 2017. (https://www.theglobalfund.org/en/news/2017-04-25-new-global-fund-grant-aims-for-malaria-elimination-in-the-mekong/, accessed 30 April 2018)
