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Multidrug resistant P. falciparum malaria is now established in parts of Thailand, Laos and Cambodia, causing high treatment failure rates for artemisinin combination therapies, the main falciparum malaria medicines.

My name is Lorenz von Seidlein and I am based in Bangkok, Thailand; I coordinate malaria elimination efforts for the Unit. My field of work includes Vietnam, Cambodia, Laos, Thailand, Myanmar.

The focus of my work is malaria elimination. What we are trying to do is find the best and the most cost efficient way to eliminate malaria. We are living in a time of historical very, very low malaria prevalence. I don't think it has ever been so low as it is now. So, there is a real chance to get rid of the parasite once and for all.

The threat is that if you have this really low prevalence and incidence of malaria, you have cornered the parasite. The parasites that can survive under these circumstances are the ones that are the strongest, that have completely adapted to this environment. These are parasites that are resistant to the traditional anti-malarial drugs.
The fear, of course, for an epidemiologist is that this population is going to expand again. And if these parasites expand, we have at the moment no good treatment for them. We need 2 or 3 anti-malarial drugs at once to get rid of malaria in these patients. It has become very expensive and complicated to treat people who have these resistant parasites.

And our fear is that if these parasite populations expand in Southeast Asia, the same thing will happen that happened before with sulfadoxine/pyrimethamine and with chloroquine even earlier: resistant parasites which arise from western Cambodian spread throughout the Greater Mekong sub-region, then make it through India. There has always been lively commerce between India and East Africa, and ultimately the parasites will arrive on the African continent.

Q: the main focus of your work is malaria elimination. What are the challenges in that work?

Lorenz von Seidlein: Malaria elimination has been going on for at least 50 years. In 1963 there was a strong drive to eliminate and eradicate malaria. They were perhaps even more optimistic than people are today. When they weren't successful, there was a resurgence of malaria.
I started working on malaria in 1995 in West Africa. We went to villages in The Gambia where every single person was parasitaemic, and that was not sub-microscopic parasitaemia: if you drew their blood and looked at the microscope, you would find parasites during the malaria season in the entire population.

Q: You are trying a lot of community engagement?

LvS: Yes, that's what it is called. Community engagement is the overarching umbrella term, but what does that mean? The one stream is having these technical solutions, but we are also very interested in finding approaches to engage whole communities. What would we have to do to make you interested in malaria elimination?

From what we have learned over the last years, the most successful way is to provide healthcare through the village healthcare worker; that builds trust. The village health care worker can be a villager who is interested in health care and wants to be trained and become better at it. We support this person with training, medication and basic diagnostic tests. As soon as there is one person stationed in a village who can take care of most fevers, malaria incidents drop very quickly. It is a very effective intervention. Building trust is not a very sophisticated technological approach. It doesn't get you into fancy journals and it doesn't give you a high impact factor, but it is absolutely essential if you want to be successful in malaria elimination.

Q: What are the benefits for you of working at MORU?

LvS: I am based here in the Mahidol-Oxford Research Unit in Bangkok. The advantages are that I am in the zone, in the area, in the region: Vietnam, Cambodia, Laos, Thailand, Myanmar. Being based here in Bangkok, I can fly to any one of these sites within half a day and start visiting field sites. If I would be based in Europe, I would have to fly first from London to Bangkok and then from Bangkok to these places, which would make it much more difficult if not impossible. And the second thing is that you get a different perspective. If you live in Washington, London or wherever, you have a little bit of a different view than if you are here, being immersed in the Asian area. I think I have a little bit better understanding here in Bangkok than if I were in another place.

Q: If you had one thing to say to governments about malaria elimination, what would it be?
LvS: As a Minister of Health, you look around and ask: where is most disease? What is the biggest problem that my nurses from the district hospitals are busy with? What are the hospital managers most concerned about? It is probably not malaria at the moment because we have it at very low levels of incidence. But it is myopic to stop the funding at this stage instead of saying: "OK, we must continue to do this and keep it at very low levels, then try to do the last push to get rid of malaria."

Lorenz von Seidlein

Targeted Malaria Elimination

Dr Lorenz von Seidlein coordinates MORU's Targeted Malaria Elimination (TME) study, which seeks to eliminate artemisinin resistant falciparum malaria by treating entire communities that have significant levels of subclinical malaria parasite infections and transmission with the antimalarial Dihydroartemisinin-piperaquine (DHA-PIP).

Malaria elimination in the Greater Mekong sub-region

A further spread from Myanmar to India then sub-Saharan Africa would be a global public health disaster. TME seeks the best ways to eliminate drug-resistant malaria, using both technical solutions and novel ways that engage entire communities.

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