Olof Hertting

Malaria is a potentially severe and fatal disease. Artemisinin combination therapy (ACT) is the first line therapy for malaria. Alarming emergence of resistance to artemisinin and partner drugs is now reported from Sub-Saharan Africa. Understanding treatment outcomes and identifying drug resistant markers could guide management and development of new treatment strategies. The purpose of this preparatory study is to plan: 1) a nationwide prospective treatment efficacy study using a new standardized follow-up protocol for all malaria patients in Sweden for detecting treatment failures, and 2) to plan a comprehensive prospective study in adults treated for Plasmodium falciparum malaria with more extensive sampling to assess parasite clearance time in relation to antimalarial drug concentrations, host immunity and parasite genomics. Within the preparatory study, we will assess current practice of diagnostics and management of malaria across Sweden. Moreover, we will perform a retrospective review of treatment outcomes since ACT was introduced, and also perform a pilot analysis of resistance mutations in available archived samples. The project involves experts in infectious diseases, pediatrics, microbiology and pharmacology

and the aim is to establish a nationwide collaborative network including all treating clinics. The findings from this project will lead to improved management and monitoring of malaria in travelers, and could also inform treatment strategies in endemic areas.

Infections are an important part of migrant health. Detecting infections could prevent potentially severe acute and chronic conditions in migrants. Migration from countries in Sub-Saharan Africa has increased. Screening programmes therefore need to address infections that are highly prevalent in this region. Despite high parasite prevalence in endemic areas, malaria, schistosomiasis and strongyloides are not included in the current screening program for migrants and evidence-based guidelines are needed. In a recent study in Sweden, we detected an unexpectedly high malaria parasite prevalence in asymptomatic migrants screened at migrant health facilities with 9% prevalence overall, and up to 35% in children. Clinical observation when assessed for treatment, have detected health issues in parasite positive individuals. This project aims at establishing the need for a screening program, including exploring the parasite prevalence and health effects in migrants from Sub-Saharan Africa, as well as developing a diagnostic platform and time frame for screening. Moreover, we will perform a pilot clusterd randomised trial to assess the impact and feasibility of screening compared to standard of care without screening. Evaluation of introducing a screening program will include feasibility, acceptability and cost-effectiveness. The project has the potential to guide screening strategies and make significant contributions to improved health in migrants from Sub-Saharan Africa.