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Unraveling Malaria’s Transmission Enigmas: From Resistance to Resilience

Malaria has been a tremendous global health challenge since the dawn of civilization. This life-threatening febrile disease is caused by Plasmodium parasites, which find their way into the bloodstream through the bite of infected mosquitoes. Despite remarkable strides in disease management and extensive research endeavors spanning years, malaria continues to assert its dominance as one of the most prevalent infectious diseases, affecting millions worldwide. As the crusade for global malaria eradication persists, numerous mysteries surrounding malaria transmission remain unsolved (WHO, 2022). The relentless evolution of Plasmodium parasites has posed a substantial obstacle to malaria treatment, giving rise to drug-resistant strains that have rendered once potent antimalarial drugs ineffective, challenging the traditional approach to combatting the disease (Klein, 2013). Additionally, the pattern of malaria transmission during the dry season is one of the most intriguing and puzzling aspects of the disease. As rains stop and mosquito populations decline, malaria transmission persists, leaving researchers and public health experts with a puzzling phenomenon that requires further understanding. This persistence stems from the enigmatic behavior of hypnozoites, dormant forms of the parasite, which adds complexity to the fight against malaria disease (Amare et al., 2022).

Beyond Mosquito Bites: The Far-Reaching Impacts of Malaria

Malaria, a vector-borne disease, is caused by Plasmodium parasites and transmitted to humans through the bites of infected female Anopheles mosquitoes. In humans, the disease is primarily caused by two parasite species: Plasmodium falciparum and Plasmodium vivax, with the former being the most dangerous and potentially fatal. Symptoms of the disease range from fever, chills and flu-like symptoms to serious outcomes such as anemia, organ failure and death. Despite decades of intensive attempts to control and eradicate malaria, the disease continues to be a serious public health problem worldwide, particularly in tropical and subtropical countries such as sub-Saharan Africa, Southeast Asia and regions of South America (Asenso-Okyere et al., 2011; Autino et al., 2012; Hay et al., 2004). Since 2000, global malaria control efforts have prevented a staggering 2 billion malaria infections and 12 million malaria-related deaths, a major global health triumph (WHO, 2021). While the 247 million cases and 619,000 deaths reported in 2022 provided relief that the COVID-19-induced rise in malaria deaths has not persisted, they were also a sobering reminder that there is still a long way to meet the 2030 malaria targets (GTS) (WHO, 2022). The GTS targets a global reduction of at least 90% in malaria case incidence and mortality rates, and elimination in at least 35 countries by 2030 (Patouillard et al., 2017). Nonetheless, progress towards malaria eradication has stalled since 2019, particularly in African countries. It is worth noting that most malaria cases exhibit mild symptoms, with only a small percentage, approximately 1-2% of those infected, experiencing severe illness and death. Since adults gain partial immunity to the parasite after years of repeated exposure, severe malaria is more prevalent in young children living in areas of high transmission, such as endemic areas (Akenji & Deas, 1994; López Del Prado et al., 2014; Van Vugt et al., 2011). Indeed, the disproportionate impact of malaria on global health cannot be disregarded: the disease unevenly affects vulnerable populations, including children and pregnant women, and hampers socioeconomic development in endemic areas. The vicious cycle of poverty and malaria persists, highlighting the critical need for an efficient vaccine.

Figure 1 - Pregnant women and children are more susceptible to malaria and have higher risk of developing severe disease (Zenartix, n.d.).

Unmasking the Enemy: Unraveling Malaria’s Road to Resistance

Concerted efforts by governments, international organizations, researchers, and communities have led to the implementation of various strategies to combat malaria. These include vector management strategies, consisting of insecticide-treated bed nets and indoor residual spraying to lower mosquito populations and decrease human-mosquito interaction (Choi et al., 2021; Pryce et al., 2022). Furthermore, it is essential to diagnose infections quickly and treat infected patients with appropriate antimalarial medications. Rapid diagnostic tests (RDTs) have transformed malaria diagnosis by allowing healthcare professionals in resource-constrained settings to diagnose the disease quickly and reliably (Wongsrichanalai et al., 2007). However, the constant interaction between the malaria parasite and its human host has fueled a dynamic arms race, with both sides developing arsenals and weapons, or in other words, evolving to gain an advantage. While the immune system responds to foreign pathogens by eliciting an effective response to eliminate or contain invading threats, malaria parasites have evolved ways to evade such responses, thereby counteracting recognition and destruction by the host's immune system. In the malaria parasite, this is accomplished through antigenic variation, or the frequent alteration of surface proteins that the parasite presents to the host's immune system, as well as by sequestration, whereby parasites adhere to the walls of blood vessels and evade recognition by the spleen and other immune components (Franke-Fayard et al., 2010; Scherf et al., 2008).

The same holds true for antimalarial drugs, as seen by the widespread rise of antimalarial resistance. Antimalarial resistance is the capacity of malaria parasites to tolerate the effects of antimalarial drugs, rendering them less efficient or no longer effective in treating the disease (Klein, 2013). Quinine, the first commercially available antimalarial drug in Europe, was extracted from the bark of the cinchona tree. Its active ingredient was first isolated in 1820 and was the mainstay of malaria treatment at the time (Renslo, 2013). In the 1930s, pharmacological research on quinine led to the development of more potent synthetic compounds, including chloroquine (CQ), which revolutionized malaria treatment. However, widespread resistance to CQ emerged in Southeast Asia and South America, increasing morbidity and mortality and hence posing a significant threat to malaria control (Payne, 1987). Artemisinin, discovered in the 1970s by Chinese scientist Tu YouYou, became the gold standard for malaria treatment due to its unprecedented potency against the Plasmodium parasite (Su & Miller, 2015). When combined with other antimalarial drugs to form ACTs (Artemisinin-based Combination Therapies), artemisinin offered a potent and highly effective approach to combating the disease. The World Health Organization (WHO) now advocates for ACTs as primary treatment for uncomplicated Plasmodium falciparum malaria cases in many malaria-endemic areas. However, emerging resistance, particularly in Southeast Asia, threatens to undermine these gains (Davis et al., 2005). The complex mechanisms underlying resistance include genetic alterations in the Plasmodium parasite and increased use of artemisinin-based therapy, further exacerbated by the spread of resistant parasites through human migration and international travel (Dondorp et al., 2009). To address artemisinin resistance, WHO and national malaria control programs monitor the effectiveness of ACTs and adjust treatment guidelines accordingly. Scientists are exploring alternative antimalarial agents and novel treatment strategies to stay ahead of emerging resistance.

Figure 2 - A malaria parasite replicates within liver cells (Mota & Real, 2017).

Eyes on the Prize: The Unyielding Efforts to Develop Malaria Vaccines

The development of an effective malaria vaccine remains one of the greatest scientific challenges of modern times. The parasite has a two-host life cycle that involves switching between a mammalian host and a mosquito vector and includes several phases, each of which posing particular challenges for vaccine development. The concept of a malaria vaccine first arose in the early 20th century, with early attempts based on the use of whole parasites. However, these methods were challenging due to the parasite's intricate life cycle and the need to keep parasites viable outside the mosquito vector (Sinden, 2010; Tran et al., 2015). Additionally, the parasite's ability to subvert the host immune system was another major challenge faced in early attempts. Added to this was the presence of different strains of parasites and a wide range of human immune responses, which hampered researchers' attempts to develop a single effective vaccine (Crompton et al., 2010; Long & Zavala, 2016). Unlike many other diseases, immunity to malaria does not develop quickly, leaving people vulnerable to recurrent infections over time. This is a major obstacle to developing lifelong immunity through vaccination.

Remarkabky, recent research has led to revolutionary achievements, such as the first-ever licensed malaria vaccine, RTS,S/AS01 (Mosquirix), targeting Plasmodium falciparum parasite (Sinnis & Fidock, 2022). While RTS,S/AS01 provided limited protection in clinical testing, it has nevertheless proven to be a significant advance in malaria vaccine development (Bojang et al., 2001); Other vaccine options include those targeting multiple Plasmodium life cycle stages, genetically engineered parasites and RNA-based vaccines (Crompton et al., 2010; Moorthy & Binka, 2021; The malERA Consultative Group on Vaccines, 2011). However, malaria primarily affects low-income regions, making funding and clinical trials challenging.

Figure 3 - A long-awaited malaria vaccine has been announced for implementation across 12 African nations over the next two years, potentially saving tens of thousands of lives (Wyatt, 2021).

Cracking the Code: Deciphering Malaria Transmission in the Dry Season

Malaria transmission and increased mosquito activity have historically been linked to the rainy season. During the rainy season, when the mosquito population is plentiful, transmission of malaria intensifies, leading to an increase in the number of cases (Odongo-Aginya et al., 2005). The reproduction and survival of the Anopheles mosquitoes depend on the presence of stagnant water, with rainfall creating ideal breeding grounds for mosquitoes and, as a result, transmission rates increase. This is a well-established and understood aspect of malaria epidemiology (Midekisa et al., 2015; Pascual et al., 2008). But what puzzles researchers and healthcare professionals is the perpetuation of malaria transmission during the prolonged dry season, when mosquito populations dwindle and breeding site availability decreases. Traditionally, the dry season was considered a time of lower malaria transmission due to unfavorable conditions for mosquito survival. However, recent studies have shown that cases of malaria persist even during the dry season, revealing a puzzling aspect of the disease's transmission dynamics (Abdel-Muhsin et al., 1998; Lindsay et al., 1991; Moiroux et al., 2012). The mysterious occurrence of malaria transmission during the dry season arises from various factors, including the presence of hypnozoites in affected individuals and the adaptation of mosquito vectors to changing environmental conditions (Amare et al., 2022; Midekisa et al., 2015). Hypnozoites are unique to certain Plasmodium species, notably Plasmodium vivax and Plasmodium ovale. Unlike other species, these parasites have evolved a remarkable adaptive mechanism that enabled them to reside in the livers of infected individuals for extended periods. This state of dormancy, also known as hibernation or latency, poses a significant hurdle to malaria control and eradication endeavors (Merrick, 2021).

The parasite's ability to trigger genetic changes and enter hibernation is crucial for the persistence of malaria, as dormant parasites evade recognition and elimination by the human immune system. Consequently, hypnozoites can survive in mosquito vectors and human hosts without triggering active disease symptoms or immune responses. When the rainy season returns, the hypnozoites can reactivate, which can lead to relapses (Kevin Baird, 2013; Merrick, 2021; Poespoprodjo et al., 2009). This ability to remain undetected allows them to survive for long periods of time, making eradication efforts challenging. In addition, hypnozoites make it difficult to correctly diagnose malaria patients, as normal diagnostic procedures often fail to detect latent parasites (Olliaro et al., 2016; Wells et al., 2010). During the dry season, there is also a remarkable change in the behavior of malaria parasites in terms of protein sequestration and adhesion. Sequestration is significantly reduced, which is associated with changes in the expression and activity of adhesion proteins on the surface of infected red blood cells (Andrade et al., 2022; Collins et al., 2022). Adherence proteins are critical to the parasite's ability to evade detection by the host's immune system and cause serious disease. These proteins allow infected red blood cells to attach to the endothelial walls of blood vessels, preventing the spleen and other immune cells from recognizing and destroying parasites. By reducing sequestration during the dry season, the malaria parasite becomes less virulent and causes milder clinical symptoms (Dicko et al., 2005). These fascinating alterations in malaria transmission patterns during the dry season deepen the mystery surrounding this tenacious illness and emphasize the need for further research to fully understand its intricacies.

Figure 4 -Unraveling the complexities of malaria's transmission is imperative to mitigate its devastating impacts (Jolly, 2015).


As the challenges posed by drug-resistant strains are confronted, the elusive quest for an effective vaccine pursued, and the enigma of malaria transmission during the dry season delved into, a steadfast commitment to combating this ancient disease must be maintained. The resilience of the malaria parasite demands for innovation and collaboration across borders and disciplines. Fostering partnerships between governments, researchers and communities can forge a united front against malaria that moves closer to the ultimate triumph of eradicating this ancient disease. A future where malaria is a distant memory, and the world enjoys equitable global health, can only be achieved through a deep comprehension of its complexities.

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Maria Inês Marreiros

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