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Clinically immune hosts as a refuge for drug-sensitive malaria parasites

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Abstract ral ss BioMed CentMalaria Journal Open AcceResearch Clinically immune hosts as a refuge for drug-sensitive malaria parasites Eili Y Klein1,2, David L Smith3, Maciej F Boni1,2,4 and Ramanan Laxminarayan*1,4 Address: 1Resources for the Future, 1616 P St., NW, Washington, DC 20036, USA, 2Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ 08544, USA, 3Department of Zoology, University of Florida, Gainesville, FL 32611, USA and 4Princeton Environmental Institute, Princeton University, Princeton, NJ 08544, USA Email: Eili Y Klein - [email protected]; David L Smith - [email protected]; Maciej F Boni - [email protected]; Ramanan Laxminarayan* - [email protected] * Corresponding author Abstract Background: Mutations in Plasmodium falciparum that confer resistance to first-line antimalarial drugs have spread throughout the world from a few independent foci, all located in areas that were likely characterized by low or unstable malaria transmission. One of the striking differences between areas of low or unstable malaria transmission and hyperendemic areas is the difference in the size of the population of immune individuals. However, epidemiological models of malaria transmission have generally ignored the role of immune individuals in transmission, assuming that they do not affect the fitness of the parasite. This model reconsiders the role of immunity in the dynamics of malaria transmission and its impact on the evolution of antimalarial drug resistance under the assumption that immune individuals are infectious. Methods: The model is constructed as a two-stage susceptible-infected-susceptible (SIS) model of malaria transmission that assumes that individuals build up clinical immunity over a period of years. This immunity reduces the frequency and severity of clinical symptoms, and thus their use of drugs. It also reduces an individual's level of infectiousness, but does not impact the likelihood of becoming infected. Results: Simula

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