Introduction: Malaria is one of the leading causes of morbidity and mortality in developing countries, with sub-Saharan Africa carrying the highest per capita burden of this disease in the world. In line with the World Health Organisation's Global Strategy for Malaria Control, which emphasises the empowerment of local communities in health decision making and positive health seeking behaviour, the KwaZulu-Natal Department of Health developed two malaria health education materials. These health education materials have since never been systematically evaluated in terms of their content, the target groups reached, and the appropriateness of the health education messages provided. The aim of this project was thus to evaluate these existing malaria health education printed materials, including their efficacy in communicating appropriate, understandable and relevant messages at community level in the malarias region of Jozini in northern KwaZulu-Natal. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2007.

Despite the concerted efforts of researchers, policy makers and public health workers worldwide, malaria persists as a significant disease threat for nearly half the world’s population. Recent advances in vector control measures, diagnostics and antimalarial drug therapies have contributed greatly to reducing the incidence of clinical disease, and by extension, the number of deaths attributable to malaria in the past two decades; however, the latter remains high—over 400,000 people die each year from malaria, the vast majority of these being children under the age of five. Our ability to rapidly and effectively treat malaria has been a cornerstone of efforts to control and eradicate this devastating disease. Nonetheless, the constant evolution and spread of drug-resistant forms of the Plasmodium parasites that cause malaria—particularly the most virulent of these, Plasmodium falciparum—have historically greatly hindered these efforts, compromising the efficacy of every previous first-line treatment. Today, treatment of P. falciparum malaria relies on artemisinin derivatives, an exquisitely potent and fast-acting class of antimalarials that are deployed ubiquitously in artemisinin-based combination therapies, or ACTs. Now, emerging resistance to ACTs threatens to once again reverse the hard-fought advances made in the global fight against malaria. Resistance to artemisinin itself was first documented in western Cambodia and northwest Thailand in 2009 and has continued to spread throughout Southeast Asia at alarming rates. Reports of resistance to ACTs followed soon thereafter. Artemisinin resistance has also emerged de novo in other parts of the world. The major concern is that it will spread to Africa, where the disease burden is highest. Previous studies have provided compelling evidence that resistance to artemisinin results primarily from specific point mutations in the C-terminal Kelch propeller domain of the P. falciparum protein K13. Here, we have addressed two central aims regarding the role of this protein in mediating resistance to artemisinin. The first was to genetically dissect the contribution of a panel of K13 polymorphisms to artemisinin resistance and parasite fitness as assessed in vitro, with the latter being a key factor impacting the spread of resistance-conferring alleles in high-transmission settings. These experiments were conducted by CRISPR-Cas9-mediated gene editing, which allowed us to successfully engineer K13 mutations into a variety of strain backgrounds, including, for the first time, recently culture-adapted African parasites. These experiments clearly show that there is no genetic obstacle to the acquisition of artemisinin resistance in African parasites; however, they also suggest that fitness costs associated with these mutations may counter-select against the spread of resistance. The second aim relating to K13 was to investigate the underlying biology of this protein. To this end, we raised monoclonal antibodies to recombinant K13 and generated transgenic lines expressing tagged versions of the protein. Using these tools, we describe the subcellular localization of K13 in wild-type and mutant parasites in the presence and absence of drug pressure, and identify potential K13-associated proteins. We also find that mutant K13-mediated resistance is reversed upon co-expression of wild-type or mutant K13, suggesting that mutations result in a loss of protein function. In order to overcome K13-mediated artemisinin resistance, novel therapeutics with distinct modes of action will be required. In our last aim, we characterize inhibitors of a particularly promising new antimalarial drug target, the proteasome. We report that these covalent peptide vinyl sulfone inhibitors are highly potent against genetically diverse parasites, including K13-mutant, artemisinin-resistant lines. Moreover, we observe that parasites do not readily acquire resistance to these compounds, nor do related compounds select for cross-resistance to one another. We also observe strong synergy between artemisinin and related compounds with these inhibitors in both K13 mutant and wild-type parasites. These results highlight the potential for targeting the Plasmodium proteasome as a means of overcoming artemisinin-resistant malaria.

Thesis submitted to the Faculty of Science, University of the Witwatersrand, in fulfilment of the requirement for the degree of Doctor of Philosophy 2019 School of Public Health University of the Witwatersrand, South Africa / Background: Spatial targeting of interventions is increasingly recognized as essential for malaria control, particularly in areas aiming for elimination. The associations between house characteristics and malaria transmission is known, but gaps remain on whether transmission is also influenced by factors such as distances between households or the degree to which houses are clustered. It is also important to identify new interventions that can be implemented by targeting critical points in the biology of major malaria vectors and common characteristics of human settlements. Such efforts will be essential to complement current major tools. Aims: This study had the following aims; (i) understand how households densities and their distances influence malaria transmission the study area , (ii) identify housing-related factors affecting residual transmission risks in the area (iii) assess opinions of residents on how house characteristics, settlement patterns and other environmental factors influencing malaria transmission, and (iv) identify effective complementary approaches that could be used to improve malaria control in these residual transmission area with high coverage of basic interventions such as long lasting treated nets. Methodology: A mixed methods approach was used, which included: (i) indoor and outdoor mosquito collections from fixed as well as randomly selected households over 12 months, (ii) characterization of physical and microclimatic conditions of the houses and surrounding environmental variables, (iii) assessing effects of spatial clustering of households on malaria transmission risks, and (iv) assessing community concerns regarding household and environmental factors influencing transmission. During these studies, swarms of Anopheles mosquitoes were discovered for the first time in this area. Therefore, additional quantitative and qualitative observations were made to characterize the swarms and assess how they could be targeted to complement malaria control efforts. Key findings: Despite the expansive use of LLINs in the area, factors associated with housing characteristics and settlement patterns as well as people’s perceptions contribute to persistent malaria transmission, and will need to be addressed for eventual elimination to be reached. The main findings of this study were as follows: (i) household occupancy influenced indoor mosquito density (ii) high house densities increased Anopheles biting risk but mosquito density declined as distances between houses increased beyond 50m; (iii) abundance of the vector Anopheles arabiensis peaked during high rainfall months (February-May), but An. funestus densities remained stable into the dry season (May-August); (iv) there were higher indoor densities of An. arabiensis and An. funestus in houses with mud walls compared to plastered or brick walls, open eaves compared to closed eaves and unscreened windows compared to screened windows; (v) most respondents were aware of associations between their house characteristics and malaria risks but carrying out improvements was constrained by financial costs and other household priorities; (vi) in all our surveys, An. funestus mosquitoes contributed approximately 85% of ongoing malaria transmission in the areas, even when occurring in far smaller densities than An. arabiensis; and (vii) with regards to complementary interventions, small scale studies demonstrated that mating swarms of both An. arabiensis and An. funestus could be readily identified and characterized (in this case by volunteer community members), and that targeting the swarms using aerosol spraying could possibly reduce overall biting risk in the communities. Conclusions: This study yielded evidence that malaria transmission risks are significantly lower when the distances between houses are high. Variation in malaria transmission risk within a village might be important for planning and implementing spatially targeted interventions. With limited resources, malaria control efforts must be prioritized in locations with significantly higher risk in order to obtain maximum benefit. Thus, the distances between houses should be considered when planning malaria vector control strategies. Furthermore, the overall clustering of indoor densities of major disease-transmitting mosquitoes is significantly associated with household occupancy and its spatial distribution within the villages. Further research is needed to assess the potential of using this information for predicting, identifying and targeting the most intense foci of mosquito-borne disease transmission based on household occupancy. Understanding the factors influencing malaria transmission at a small scale is crucial for planning malaria control interventions. Malaria transmission heterogeneity does not only exist on a large scale, but also at small scales, which may be influenced by small variations of environmental features, such as seasonality. These variations should be considered when improving malaria control interventions. While An. funestus showed variation in density during the year, numbers of mosquitoes remained high throughout the dry season, whereas An. arabiensis showed a definite peak in the rainy season with a subsequent drop during the dry season. Further studies are required to investigate the survival strategies of major malaria vectors during the dry season. Understanding this particular feature of An. funestus may lead to the design of new control strategies or improve existing interventions so as to reduce the malaria burden in such rural areas. This study also documented high mosquito densities in mud-walled houses compared to houses with brick or plastered walls. These findings further indicate the necessity of considering house improvement as a malaria control strategy. While the community members had fairly high awareness that improved houses were associated with reduced mosquito nuisance, many families in rural areas are living in poorly constructed houses. It is therefore necessary to consider inter-sectoral collaborations to integrate housing into health policies in Tanzania. Further studies are also needed to provide epidemiological evidence on how housing design affects malaria transmission. Furthermore, community-based house improvement programs should be promoted, including simple, scalable and affordable house improvements for the populations living in high malaria endemic areas in rural communities. Generally, this study has generated information which sets the basis for further studies on the relationship between the exact house location and malaria transmission risk in rural malaria endemic countries. / MT 2020

Malaria is a major health problem, mainly in developing countries, and causes an estimated 1 million deaths per year. Plasmodium falciparum is the major type of human malaria parasite, and causes the most infections and deaths. Malaria drugs, like any other drugs, suffer from possible side effects and the potential for emergence of resistance. Chloroquine, which was a very effective drug, has been used since about 1945, but its use is severely limited by resistance, even though it has mild side effects, and is otherwise very efficacious. Research has shown that there are chloroquine reversal agents, molecules that can reinstate antimalarial activity of chloroquine and chloroquine-like drugs; many such reversal agents are composed of two aromatic groups linked to a hydrogen bond acceptor several bonds away. By linking a chloroquine-like molecule to a reversal agent-like molecule, it was hoped that a hybrid molecule could be made with both antimalarial and reversal agent properties. In the Peyton Lab, such hybrid "Reversed Chloroquine" molecules have been synthesized and shown to have better antimalarial activity than chloroquine against the P. falciparum chloroquine-sensitive strain D6, as well as the P. falciparum chloroquine-resistant strains Dd2 and 7G8. The work reported in this manuscript involves simplifying the reversal agent head group of the Reversed Chloroquine molecules, to a single aromatic ring instead of the two rings groups described by others; this modification retained, or even enhanced, the antimalarial activity of the parent Reversed Chloroquine molecules. Of note was compound PL154, which had IC50 values of 0.3 nM and 0.5 nM against chloroquine-sensitive D6 and chloroquine-resistant Dd2. Compound PL106 was made to increase water solubility (a requirement for bioavailability) of the simplified Reversed Chloroquine molecules. Molecular modifications inherent to PL106 were not very detrimental to the antimalarial activity, and PL106 was found to be orally available in mice infected with P. yoelli, with an ED50 value of about 5.5 mg/kg/d. Varying the linker length between the quinoline ring and the protonatable nitrogen, or between the head group and the protonatable nitrogen, did not have adverse effects on the antimalarial activities of the simplified Reversed Chloroquine molecules, in accord with the trends observed for the original design of Reversed Chloroquine molecules as found from previous studies in the Peyton Lab. The simplified Reversed Chloroquine molecules even tolerated aliphatic head groups (rather than the original design which specified aromatic rings), showing that major modifications could be made on the Reversed Chloroquine molecules without major loss in activity. A bisquinoline compound, PL192, was made that contained secondary nitrogens at position 4 of the quinoline ring (PL192 is a modification of piperaquine, a known antimalarial drug that contains tertiary nitrogens at position 4 of the quinoline ring); this compound was more potent than piperaquine which had an IC50 value of 0.7 nM against CQS D6 and an IC50 of 1.5 nM against CQR Dd2, PL192 had IC50 values of 0.63 nM against chloroquine sensitive D6 and 0.02 nM against chloroquine resistant Dd2. Finally, the mechanism of action of these simplified "Reversed Chloroquines" was evaluated; it was found that the simplified "Reversed Chloroquines" behaved like chloroquine in inhibiting β-hematin formation and in heme binding. However, the simplified "Reversed Chloroquines" were found to inhibit chloroquine transport for chloroquine resistant P. falciparum chloroquine resistance transporter expressed in Xenopus oocytes to a lesser extant than the classical reversal agent verapamil. From these studies it was noted that the simplified "Reversed Chloroquines" may not behave as well as classical reversal agents would in restoring chloroquine efficacy, but they are very potent, and so could be a major step in developing drug candidates against malaria.

PhD, Faculty of Science, University of the Witwatersrand, 1999

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: The work in this dissertation provides structural and kinetic insight into the mechanism of action of quinoline antimalarial drugs which may aid rational drug design. Quinoline antimalarial drug-ferrihaem (Fe(III)PPIX) complexes were investigated. Single crystal Xray diffraction (SCD) structures of the complexes formed between Fe(III)PPIX and the quinoline methanol antimalarials quinine, quinidine and mefloquine have been determined, and are the first observed structures of complexes formed between free Fe(III)PPIX and quinoline antimalarial compounds. Quinine, quinidine and mefloquine are shown to have a three-point binding mode to Fe(III)PPIX, which comprises direct coordination of the drug to the Fe(III) centre through its benzylic alcohol functionality, π-stacking between the drug and porphyrin aromatic systems, and intramolecular hydrogen bond formation between the porphyrin propionate group and the protonated quinuclidine nitrogen atom of the drug in the case of quinine and quinidine, and formation of an intramolecular hydrogen bonding network in the case of mefloquine. Extended X-ray absorption fine structure spectroscopy (EXAFS) was use to elucidate structural information of Fe(III)PPIX-drug complexes in solution, and indicates that coordination persists in solution. The protocol for lipid-mediated formation of β-haematin, where monopalmitic glycerol was used as a model lipid, was successfully modified to incorporate antimalarial drugs into the aqueous layer in order to investigate drug activity under biologically-relevant conditions. Four compounds were chosen, namely chloroquine and amodiaquine, both 4- aminoquinolines and quinine and quinidine. IC50 values for the inhibition of β-haematin formation show good correlation with biological activities determined against a chloroquine-sensitive Plasmodium falciparum strain. The lipid-water interface system was further used to investigate the effects of quinine, quinidine chloroquine and amodiaquine on the kinetics of β-haematin formation. The results led to the development of a kinetic model based on the Avrami equation and the Langmuir isotherm. The data strongly support a mechanism of antimalarial drug action by adsorption to the growing face of haemozoin, with precipitation of Fe(III)PPIX at high drug concentrations accounting for decreased yields. Adsorptions constants (log Kads) determined for each drug show a strong correlation with biological activity. Finally, the first SCD structure of the μ-propionato dimer of Fe(III)PPIX, the structural unit of haemozoin, has been determined as its DMSO solvate. EXAFS suggests that this species is only formed upon nucleation, with the π-π dimer species being favoured in solution. / AFRIKAANSE OPSOMMING: Die werk in die dissertasie verleen struktuur en kinetiese insig in the meganisme van aktiwiteit vir kinolien antimalariamiddels wat kan bydra tot die ontwikkeling van nuwe medisyne. Kinolien antimalariamiddel-ferriheem (Fe(III)PPIX) komplekse was ondersoek. Navorsing is gedoen op die enkelkristal X-straaldiffraksie strukture van die komplekse gevorm tussen Fe(III)PPIX en die kinolien metanol antimalaria middels kinien, kinidien en mefloquine. Die strukture is die eerste komplekse wat waargeneem is tussen vrye Fe(III)PPIX en kinolien antimalariamiddels. Kinien, kinidien en mefloquine het ʼn driepunt bindingsvorm, direkte koördinasie met die Fe(III) deur die bensielalkohol groep, ʼn π- stapel tussen die middel en die porfirien aromatiese sisteem, ʼn intramolekulêre waterstofbinding tussen the porfirienpropionaat funksie en die geprotoneerde kinuklidien stikstofatoom (kinien en kinidien) en ʼn netwerk van intramolekulêre waterstof bindings (mefloquine) insluit. Uitgebreide X-straal absorpsie fyn struktuur spektroskopie (EXAFS) is gebruik om inligting oor Fe(III)PPIX-middel komplekse in oplossing te verkry en het aangedui dat die koördinasie in oplossing voorkom. Deur gebruik te maak van monopalmitiengliserol as die lipid in the lipid-water interfase sisteem, waar antimalariamiddels suksesvol in die buffer geïnkorporeer was, was die middel se aktiwiteit onder biologiese kondisies geondersoek. Vier middels was gekies naamlik, chloroquine en amodiaquine, albei 4-aminokinoliene en kinien en kinidien om die IC50-waarde vir inhibisie van β-hematien vorming te bepaal. Die IC50 waardes het ʼn goeie korrelasie met biologiese aktiwiteite teen die chloroquine-sensitiewe Plasmodium falciparum stam gewys. Die lipid-water interfase-sisteem was ook gebruik om die effek van kinien, kinidien, chloroquine en amodiaquine op die kineties effek op die vorming van β-hematien te ondersoek. Die resultate het gelei to die ontwikkeling van die kinetiese model gebaseer op die Avrami vergelyking en die Langmuir isoterm. Die data ondersteun ʼn meganisme van middel aksie waar die middel teen die groeiende vlak van hemosoïen kristal adsorbeer. Die neerslag van Fe(III)PPIX wat vorm by hoë konsentrasies, het gelei tot laer opbrengste. Die adsorpsiekonstante (log Kads) bepaal vir elke middel, het goeie korrelasie met biologiese aktiwiteit getoon. Enkelkristal X-straaldiffraksie strukture van μ- propionatodimeer van Fe(III)PPIX, die struktuur eenheid van hemosoïen, was bepaal as ʼn DMSO solvaat. EXAFS het aangedui dat die spesie slegs by kernvorming ontstaan en dat die π-π dimeerspesie in oplossing voorkom.

A thesis submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy. December 2, 2014. / Malaria is a public health problem for more than 2 billion people globally. About 219 million cases of malaria occur worldwide and 660, 000 people die, most (91%) in the African region despite decades of efforts to control the disease. Although the disease is preventable, it is life-threatening and parasitically transmitted by the bite of the female Anopheles mosquito. A deterministic mathematical model with intervention strategies is developed in order to investigate the effectiveness, optimal control and cost effectiveness of Indoor Residual Spraying (IRS), Insecticide Treated Nets (ITNs) and treatment on the transmission dynamics of malaria in Karonga District, Malawi. The effective reproduction number is analytically computed, and existence and stability conditions of the equilibria are explored. The model does not exhibit backward bifurcation. A structured questionnaire was developed, a one-toone interview with a randomly sampled set of individuals conducted to assess the knowledge level of inhabitants of Karonga district about the disease in general and their awareness and application of the intervention strategies. Applying Pontryagin’s Maximum Principle which uses both the Langragian and Hamiltonian principles with respect to a constant time dependent, we derive the necessary conditions for the optimal control of the disease. An economic evaluation of the strategies is carried out by performing a cost-effectiveness analysis to determine the most cost-effective combination of the three intervention measures. The incremental cost-effectiveness ratio (ICER) is calculated in order to compare the costs and effectiveness of all the possible combinations of the three measures. The results show that the combination of treatment, ITNs and IRS is the most cost-effective combination strategy for malaria control. Numerical simulations indicate that the prevention strategies lead to the reduction of both the mosquito population and infected human individuals. Effective treatment consolidates the prevention strategies. Thus, malaria can be eradicated by deployment of combined strategies such as vector control via ITNs and IRS complemented with timely treatment of infected people.

Malaria disease poses a serious global health burden as recent reports have indicated that nearly half of the world’s population is at risk (WHO 2008). The World Health Organization (WHO) Expert Consultative Team has reported that 90% of all malaria deaths occur in Sub Saharan Africa. (WHO, 2008). Despite the numerous global efforts to control and manage the disease, through various ways, use of chemotherapeutic agents continues to be the major intervention strategy in the control of malaria. The WHO recommended use of Artermisinin combination therapy (ACT) has been hampered by an imbalance between demand and supply in the poor socioeconomically challenged rural populations of Sub Saharan Africa, the epicenter of malaria infection. Chloroquine (CHQ), therefore, continues to be used in most malaria endemic areas in developing countries despite development of P. falciparum resistance to the drug (WHO, 2006). Oral administration is the major delivery route for CHQ. However, CHQ is a bitter drug, with an inconvenient dosing schedule leading to incomplete courses of therapy by most malaria patients. Oral CHQ administration is also associated with adverse effects in various organ systems resulting from deposition of CHQ in these organs to elicit impairment of glucose homeostasis, renal and cardiovascular function. Alternative methods of CHQ administration such as transdermal delivery have, therefore, been suggested, in an effort not only to avoid the bitter taste, but also to modify the dosing schedule, which may improve patient comfort and compliance. Transdermal delivery of CHQ via an amidated matrix patch, which is envisaged to ensure a slow, controlled and sustained release of therapeutic concentrations of CHQ, may circumvent the previously reported adverse effects of oral CHQ. It is against this background that the current study compared the effects of transdermal CHQ patch and oral chloroquine in the management of malaria as assessed by the ability to clear parasites of P. berghei infected rats. The other aims were to investigate and distinguish between the patho physiological effects of malaria and CHQ treatments on blood glucose and plasma insulin concentration, renal and cardiovascular function in male Sprague-Dawley rats. To investigate and distinguish between the pathophysiological effects malaria infection and CHQ treatments on blood glucose homeostasis, renal and cardiovascular function markers, separate groups of non infected and P. berghei infected male Sprague Dawley rats (90g-150g) were used. The animals were treated twice daily with oral CHQ (60mg/kg) and a once off transdermal delivery of CHQ via topical application of pectin CHQ matrix patch (53mg/kg) in a 21 day study divided into pre treatment, (days 0-7) treatment (days 8-12) and post treatment (days 13-21) periods. The animals were housed individually in metabolic cages for the duration of the study. Treatment was for 5 consecutive days. Measurements of body weight, food and water intake, mean arterial pressure (MAP), blood glucose concentration, % parasitaemia, haematocrit, and 24 hour urine volume, Na+, K+, urea and creatinine outputs were done every day during the treatment period, and every third day during the pre and post treatment periods. Separate groups of non fasted conscious animals (n=6) were sacrificed on days 0, 7, 8, 9, 10, 12, 14 and 21, at 24 hours after the last treatment for oral CHQ administration and after a once off patch application on the first day of treatment. The plasma obtained was assayed for plasma insulin, lipid profile parameters and plasma Na+, K+, urea and creatinine. The harvested liver and gastrocnemius muscle were used for determination of glycogen concentration. The current study has demonstrated the sustained controlled release of CHQ from the pectin matrix patch, demonstrating the therapeutic ability to clear P. berghei malaria parasites from systemic circulation. Malaria infection and oral CHQ treatment exhibited blood glucose lowering effects which were circumvented by topical application of the pectin CHQ matrix patch. Oral CHQ elevated hepatic glycogen concentration through mechanisms that are still to be elucidated. Topical application of CHQ via pectin matrix patch did not alter hepatic and gastrocnemius muscle glycogen concentrations. Malaria infection and oral CHQ delivery reduced food intake, water intake and % body weight changes of the animals as well as inducing natriuresis, reduced urine output and increased urinary creatinine outputs. Malaria infection was also shown to elicit hyperkalaemia and kaliuresis in experimental animals. Hypotensive effects of malaria infection and oral CHQ delivery were also demonstrated in the current study. Malaria infection and oral CHQ delivery elevated plasma total cholesterol and LDL-c as well as reduction in the cardio protective particle, plasma HDL-c, concentrations. Topically delivered CHQ via pectin CHQ matrix patch did not evoke any such alterations, suggestive of its ability to circumvent the observed adverse effects of oral CHQ delivery due to sustained, controlled release of therapeutic concentrations of CHQ from the transdermal formulation. To the best of our knowledge, the results of the present study provides the first evidence of the release of therapeautic CHQ concentrations from pectin CHQ matrix patch that cleared the malaria parasites from systemic circulation as well as demonstrating the ability of the transdermal formulation to circumvent the adverse effects of oral CHQ delivery in glucose homeostasis, renal and cardiovascular function markers. This is clinically relevant as it provides a feasible and novel alternative method of CHQ delivery that could play a major role in the effective management of malaria. / Thesis (Ph.D.)-University of KwaZulu-Natal, Westville, 2011.

Pyrimethamine efficacy was investigated in vitro on the blood asexual stages, the sexual stages and exflagellation in Plasmodium falciparum. Gametocytogenesis was stimulated following the standard methods on five isolates of Plasmodium falciparum. From these five isolates, RSA 2, 3 and 5 produced gametocytes which reached maturity within seven days and the gametocytes were able to exflagellate. Isolate MW2 produced young gametocytes which disappeared within ten days. NF54 produced mature gametocytes which lasted for 24 hours only. There were no statistically significant differences between the static and the synchronization methods of gametocyte stimulation for any of the isolates. The effect of pyrimethamine was investigated by adding a known concentration of the drug (For RSA 2, MW2 and NF54, l00nmol/ℓ; RSA 3 and 5, 3000nmol/ℓ pyrimethamine) to the culture medium for seven days during gametocyte stimulation. The results of this investigation show that there was gametocytocidal activity on the isolates that were used and pyrimethamine also had a schizontocidal action on NF54 and the young gametocytes of this isolate were destroyed by the drug. At concentrations which were inhibitory to asexual parasites, the drug had a sporontocidal effect on isolate RSA 2 but not on isolate RSA 5. The pyrimethamine MIC values for asexual parasites ranged from 300nmol/ℓ to > 3000nmol/ℓ (RSA 2 and 5 were not inhibited at 3000nmol/ℓ ). These results are consistent with those found in previous studies when pyrimethamine resistance was first detected in South Africa. The chloroquine MICs indicate a good correlation with the results obtained from previous drug sensitivity tests for all the isolates examined using both the 48-hour in vitro test and isotope incorporation for growth assessment. The isobolograms constructed to determine relationship between chloroquine and pyrimethamine indicated no synergism for isolates RSA 2 and 5, but the Σ relative IC[50]s indicated a weak synergism. Both the isobolograms and the Σ relative IC[50]s for the isolates RSA 6, 9 and 14 indicated an antagonistic action between chloroquine and pyrimethamine. The results obtained from this study have important implications for malaria control in South Africa. / Thesis (M.Sc.)-University of Natal, Pietermaritzburg, 1995.

Malaria is the one of most important diseases in the world, especially in sub-Sahara Africa. This dissertation outlines the enormous burden of the disease in terms of social and economic costs in southern Africa. This dissertation assessed the range and quality of the cost-effectiveness of malaria prevention in sub-Sahara Africa. Six studies published from 1999 to 2003 are reviewed, covering insecticide treated nets, residual spraying, chemoprophylaxis for infants and environmental management. For infants, ITNs cost from US$ 2019 - $2879 per death averted and cost $ III per DALY; chemoprophylaxis cost $ 4.1 per DALY and chemoprophylaxis plus iron cost $ 5.0 per DALY. For children, ITNs cost $ 1559 per death averted, $ 57 per DALY and $ 61 per sick child averted. For non-specific age group, ITNs cost $ 29 per infection averted, and RHS $ 9. Generally all interventions assessed are cost effective use of resources. The chemoprophylaxis is the least expensive malaria prevention among cost effective malaria prevention interventions, followed by residual spraying one round a year, residual spraying two rounds a year, insecticide treated nets with net treatment only and insecticide treated nets with net provision and treatment. There are operational, managerial and financial challenges faced these most cost-effective malaria interventions. Particularly, chemoprophylaxis is faced the tremendous drug resistance potential and is not being recommended to wide use; financial constraints and the potential delaying of children's immunity acquisition lowers the cost-effectiveness of insecticide treated nets; residual spraying is a relatively simpler, faster and cheaper method, but faces political and economic pressure of concerning environmental issues, especially the use of DDT. The integrated approach of environmental management plus residual spraying could be the most cost-effective method of malaria prevention with least adverse environment effects. However, policy makers should apply their knowledge to local conditions. Further, comprehensive education programmes are needed to gain support and understanding from local communities. This would raise the cost-effectiveness of all interventions. / Thesis (M.B.A.)-University of Natal, Durban, 2003.