<p>Malaria is a health, social and economic burden in Nigeria and consistently ranks amongst the four most common causes of childhood deaths. Treatment of malaria is usually started at home / care is only sought from the health facility when the treatment is ineffective (McCombie, 1996). Patent medicine vendors (PMVs) have been identified as a widely patronized source for drugs used in the home treatment of malaria (Breiger et al, 2001 / Goodman, et al, 2007 / Salako et al, 2001). Inadequate or poor knowledge and practices in the use of anti-malaria drugs (AMDs) increases morbidity and mortality, undermines therapeutic efficacy, and promotes the emergence and spread of drugresistant malaria. Aim: The aim of the study was to describe and quantify the knowledge and self-reported practices of PMVs in the use of antimalarials, particularly artemisinin-based combination therapies (ACTs), in a poor urban community in Lagos state, Nigeria.</p>

Malaria afflicts 300-500 million people in the world and the mortality ranges from 1-2 million, children in Africa being the most susceptible. With a vaccine not being available against malaria and the front line drugs such as chloroquine and antifolates registering widespread parasite resistance, the challenge of malaria treatment is a formidable task. While, research to discover new drugs has become essential, it has also become necessary to identify therapeutic strategies in the short-term. One approach is to examine whether known drugs used for other applications can be used to treat malaria. A second strategy is to look for natural compounds for antimalarial activity either singly or in combination. Combination therapy has assumed considerable importance in the context of artemisinin derivatives being the sole, tested, efficacious antimalarials left in the basket. A combination therapy with artemisinin derivative may prevent recrudescence due to monotherapy, extend the life of the drug and perhaps bring down the cost of therapy as well. A primary requirement to embark on such studies is to assess the status of drug resistance to the front line drugs in use. In India, chloroquine is still used as the front line drug for malaria therapy. Although, there have been indications and sporadic reports on the development of chloroquine resistance in the country, there has not been a detailed molecular or clinical evaluation for resistance. Keeping all these considerations in mind, the objectives of the present study are as follows: 1. Evaluation of chloroquine resistance inP.falciparum isolates from patients using Pfcrt-mutation as marker. 2. Evaluation of the anti-tubercular drugs, rifampicin and isonicotinic acid hydrazide (INH) for antimalarial activity. 3. Evaluation of curcumin from turmeric singly and in combination with α,β- arteether for antimalarial acitivity. Chapter I deals with the review of literature pertaining to scenario of available antimalarials, efforts to discover new antimalarials based on new drug targets, mechanisms of drug resistance and strategies for combination therapies. Chapter II deals with an evaluation of Pfcrt mutation in clinical samples of P.falciparum malaria in India. After several false starts to find molecular markers to identify chloroquine resistance, mutations in the Pfcrt gene of P.falciparum, K76T mutation in particular, has been shown to correlate very well with chloroquine resistance in culture. A study of 109 P.falciparum – infected blood samples from different parts of India has revealed that close to 95% of the isolates carry the K76T mutation. This was shown on the basis of susceptibility to ApoI restriction digestion of the PCR product covering this region (264 nt) and DNA sequencing of the PCR product. Interestingly, the resistant haplotype in this region of 72-76 amino acids was found to be mostly SVMNT, except for 4 samples with CVIET haplotype. SVMNT has all along been considered to be of South American origin, where as CVIET is of South East Asian/African origin. Subsequent studies by another group in the country has also shown that the Pfcrt - K76T mutation is seen at least in 85% of the cases and in addition to the dominant SVMNT haplotype, newer haplotypes are also seen. The present study has also included an analysis of N86Y mutation in the Pfmdr1 gene based on susceptibility to Afl III restriction enzyme digestion and DNA sequencing of the PCR product (603 nt). Pfmdr1 mutations have been extensively studied in literature for possible correlation to CQR. The net conclusion is that it does not contribute directly to CQR but may have an indirect correlation. It has been shown in Mali that there is very good correlation between Pfcrt - K76T mutation and Pfmdr1 - N86Y mutation in the P.falciparum isolates. However, in the present study with Indian isolates only around 30% of the samples were found to carry the Pfmdr1 - N86Y mutation. While, further studies on the clinical relevance of the extensive Pfcrt mutation seen in the Indian isolates are needed, it is clear that the genetic change towards chloroquine resistance has already taken place in the Indian context. Chapter III is devoted to a study of the antimalarial effects of the anti-tubercular drugs, rifampicin and INH. This is on the basis that rifampicin is an inhibitor of prokaryotic and mitochondrial/chloroplast RNA polymerase. P.falciparum harbors the apicoplast, a remnant of chloroplast with a 35kb DNA. It is known that the β, β’- subunits of the apicoplast RNA polymerase are coded by the apicoplast DNA. There is a report that rifampicin is a slow acting antimalarial in cases of P.vivax -nfection. INH is known to act by inhibiting the enoyl-ACP reductase and β - hydroxy ACP synthase in M.tuberculosis. While, M.tuberculosis is known to manifest Fab I and Fab II pathways of fatty acid biosynthesis, it has recently been shown that P.falciparum manifests the FabII (discrete enzymes) pathway. Thus, it was considered possible that INH may also inhibit the fatty acid biosynthetic pathway of P.falciparum leading to inhibition of phospohlipid and membrane biosynthesis. Studies were, therefore, carried out with rifampicin, INH and the combination on the survival of P.falciparum in culture and P.berghei in mice. With P.falciparum, growth was followed by measuring3[H]-Hypoxanthine incorporation and slide detection of parasites using Giemsa stain. The results indicate that while, rifampicin inhibits P.falciparum growth with an IC50 around 25nM, and INH fails to show any effect even at 200µM concentration. The combination of rifampicin (25nM) and INH (100µM) shows enhanced killing effect. In view of these results, studies were undertaken in mice infected with P.berghei. After 72 hr infection, the mice were orally fed with rifampicin (500 µg/40 g body weight) or INH (1 mg/40 g body weight) or a combination of the two orally for 5 days, starting on day 3. Apart from parasite clearance in blood, protection against mortality is a good index, since all the infected mice die in about 7-8 days. The results indicate that rifampicin leads to around 50% protection and INH treatment gives around 10% protection. However, the combination gives around 83% protection with complete clearance of the parasite in blood. Short- term treatment of infected mice with drugs and an assay of rpoB/C transcription in the parasite using appropriate PCR primers reveal a striking inhibition in combination treatment. Again, when such parasites were put into short-term culture and32P- incorporation into phospholipids was measured, there was striking inhibition with combination treatment. Thus, the results indicate that a combination of rifampicin and INH has potent antimalarial activity in P.berghei-infected mice. The results are dramatic in this case when compared to the results obtained with P.falciparum culture. It is not clear whether the differences are due to differences in action in vitro vs in vivo or due to differences in susceptibility between P.falciparum and P. berghei to the treatment provided. Chapter IV deals with the antimalarial activity of curcumin (diferuloyl methane) from turmeric singly or in combination with artemesinin or its derivative. Curcumin is reported to have a wide variety of biochemical effects and its anti-cancer activity is under serious investigation. There is an earlier report that curcumin shows antimalarial activity against chloroquine-sensitive P.falciparum. In the present study, curcumin was tested against a chloroquine-resistant culture of P.facliparum and it inhibits growth with an IC50 of 5-8 µM. When P.berghei-infected mice were orally fed with curcumin for 5 days, there was delay in the development of parasitemia, with about 30% of the animals protected against mortality by day 28. For reasons mentioned earlier curcumin was tested in combination with artemisinin/derivative in P.falciparum culture and P.berghei in mice. The results indicate that artemisinin and curcumin have an additive inhibitory effect on P.falciparum growth, based on a detailed analysis of the isobolograms. In terms of the mechanism of action, curcumin treatment leads to accumulation of45Ca in the parasite cytoplasm. It also has a striking inhibitory effect on32P-incorporation into parasite proteins and phospholipids, suggesting an interference with phosphorylation mechanisms. None of these effects are seen under artemisinin treatment, which has been reported to specifically inhibit PfATP6 (Ca ATPase) in P.falciparum. In view of the possible different modes of action of artemisinin and curcumin, the combination was tested in P.berghei-infected mice. The infected mice received a single injection of α,β-arteether and 3 oral doses of curcumin (5mg/30g body weight). Curcumin treatment was found to dramatically delay the onset of parasitemia seen in animals treated with α,β-arteether alone due to recrudescence. In particular, a combination with a single injection of α,β-arteether (750µg or 1.5mg/30g body weight) followed by 3 oral doses of curcumin leads to complete prevention of recrudescence and 100% protection against mortality. Several combinations with artemisinin derivative are under investigation and they all suffer from toxic side effects, pharmacokinetic mismatch, known resistance to the combining partner and high cost. It is felt that this artemisinin derivative curcumin combination could prove superior in view of the fact that no resistance is known to curcumin and is safe even at very high doses used in the human. Both the drugs are eliminated fast and curcumin is a cheap chemical and available in plenty from natural source (turmeric). In view of these positive attributes, a clinical trial with this combination is recommended. 121

<p>Malaria is a health, social and economic burden in Nigeria and consistently ranks amongst the four most common causes of childhood deaths. Treatment of malaria is usually started at home / care is only sought from the health facility when the treatment is ineffective (McCombie, 1996). Patent medicine vendors (PMVs) have been identified as a widely patronized source for drugs used in the home treatment of malaria (Breiger et al, 2001 / Goodman, et al, 2007 / Salako et al, 2001). Inadequate or poor knowledge and practices in the use of anti-malaria drugs (AMDs) increases morbidity and mortality, undermines therapeutic efficacy, and promotes the emergence and spread of drugresistant malaria. Aim: The aim of the study was to describe and quantify the knowledge and self-reported practices of PMVs in the use of antimalarials, particularly artemisinin-based combination therapies (ACTs), in a poor urban community in Lagos state, Nigeria.</p>

Le paludisme reste l'une des plus redoutables maladies infectieuses avec plus de 200 millions d'infections et près de 430 000 décès chaque année, principalement des enfants de moins de 5 ans vivant en Afrique subsaharienne. L'espèce Plasmodium falciparum est responsable de la grande majorité de la mortalité. Le contrôle de l'endémie palustre reste encore aujourd'hui un problème majeur de santé publique, notamment à cause des résistances aux antipaludiques développées par les parasites. L'apparition de ces résistances s'opère par la pression de sélection médicamenteuse, et leur diffusion progressive se fait principalement via le déplacement des hôtes infectés. Cependant, la dynamique d'émergence, de diffusion et de persistance des parasites résistants résulte d'interactions complexes entre les antipaludiques, l'Homme, le parasite et le vecteur. Le travail présenté ici participe à la démarche de lutte contre le paludisme en proposant tout d'abord un état des lieux de la résistance de Plasmodium aux antipaludiques utilisés au Cameroun, avec des outils moléculaires, phénotypiques et cliniques. Une deuxième partie explore, in vitro, les possibles conséquences d'une utilisation prolongée des dérivés d'artémisinine sur le phénotype de P. falciparum, alors que la résistance à cette molécule est déjà installée. Le modèle in vitro utilisé a permis de mettre en évidence un nouveau profil de pluri-résistance suite à des pressions continues à l'artémisinine. Enfin, une dernière partie de ce travail analyse le rôle du moustique dans l'épidémiologie des résistances et montre que la sporogonie favoriserait la diffusion des allèles minoritaires, résistants ou non, présents chez l'Homme. L'ensemble de ces travaux confirme la multiplicité des facteurs agissants sur la dynamique de résistance et la complexité de leurs interactions rendant toute prévision très spéculative. Même si une meilleure connaissance des phénomènes sociétaux, épidémiologiques, biologiques et pharmacologiques impliqués dans les résistances reste une priorité, la surveillance phénotypique et génotypique régulière sur le terrain apparait à ce jour, le meilleur outil pour adapter au mieux les stratégies de contrôle du paludisme. / Malaria remains one of the most terrible infectious diseases with more than 200 million infections and 430,000 deaths each year, mostly children under five years old in sub-Saharan Africa. Plasmodium falciparum is responsible for the vast majority of malaria mortality cases. Control of malaria still remains a major public health problem, in particular because of resistances to antimalarials that parasites developed. The apparition of these resistances is due to the drug pressure, and their progressive diffusion is mainly via the travelling of infected hosts. However, the dynamics of emergence, diffusion and persistence of resistant parasites result from complex interactions between the antimalarials, the Human, the parasite and the vector. The work presented here participates in the malaria control process by first proposing an inventory of Plasmodium resistance to antimalarials used in Cameroon, thanks to molecular, phenotypic and clinical tools. A second part explores the possible consequences of prolonged use of artemisinin derivatives on the P. falciparum phenotype, in areas where resistance to this molecule is already established. The in vitro model used showed that continuous artemisinin pressures induced a new pluri-resistance profile. Finally, a last part analyses the role of the mosquito in the epidemiology of resistances and shows that the sporogony favours the diffusion of minority alleles, resistant or not, presented in humans. All this work confirms the multiplicity of forces acting on the dynamics of resistances and the complexity of their interactions making any prediction very speculative. Even if better knowledge of the societal, epidemiological, biological and pharmacological phenomena involved in resistances is a priority, regular phenotypic and genotypic surveillance in the field remains the best tool for adapting malaria control strategies.

Introduction : Bien que les données officielles fassent état d’une diminution globale du nombre de cas de paludisme en Guyane, les orpailleurs travaillant sur les sites illégaux au cœur de la forêt amazonienne semblent très touchés par cette pathologie. L’objectif principal de cette étude était de déterminer la prévalence du paludisme dans cette population. Les objectifs secondaires évaluaient la proportion des différentes espèces plasmodiales et leur distribution géographique, le niveau de résistance des parasites aux dérivés de l’artémisinine, les connaissances attitudes et pratiques vis à vis de cette pathologie, et des données de santé de cette population. Matériel et méthodes : Les inclusions ont eu lieu sur les sites de repli des orpailleurs le long du fleuve Maroni. Après recueil du consentement éclairé, un test de diagnostic rapide du paludisme était effectué, ainsi qu’un questionnaire, un examen clinique, et un prélèvement de sang pour microscopie, PCR et tests de résistance (RSA et génotypage du gène pfK13 pour les PCR positives à Plasmodium falciparum). Résultats : De janvier à juin 2015, 421 orpailleurs ont été inclus, majoritairement des hommes (70,6%) brésiliens (93,8%), de médiane d’âge de 37 ans. La prévalence du portage de plasmodies déterminée par PCR était de 22,3% (IC95% : 18,3-26,3) à 84% asymptomatiques. Les espèces identifiées étaient principalement P. falciparum (47,9%) puis P. vivax (37,2%) avec 10,6% de coinfections. Lors du dernier accès palustre, 52,4% des orpailleurs avaient eu recours à l’automédication, majoritairement avec des dérivés de l’artémisinine (93,8%) avec une mauvaise observance (37,8%). Le fait d’être en Guyane était fortement associé à l’automédication (AOR=22,1). Le test RSA montrait un taux de survie supérieur à 1% pour un échantillon mais l’analyse du gène pfK13 ne mettait pas en évidence de mutations associées à la résistance à P. falciparum Discussion: La prévalence élevée de porteurs asymptomatiques de paludisme constitue un réservoir important pourla transmission du paludisme dans la région. L’utilisation massive de dérivés de l’artémisinine associée à une mauvaise observance sont des facteurs de risque d’émergence de résistance, ce qui entraînerait des conséquences sanitaires et économiques importantes. Avec une volonté politique, des actions sont possibles pour limiter ce risque, comme la distribution de kits d’autodiagnostic et d’auto-traitement avec une formation au niveau des sites de repli. / Introduction: Although official data show a global decrease of malaria in French Guiana, this disease often affects illegal gold miners working in the deep Amazonian forest. The main objective of this study was to evaluate the malaria prevalence in this population. The secondary objectives were to evaluate and map the proportion of Plasmodium species, to assess behavior, attitudes and practices regarding malaria in this population, to measure the artemisinin resistance level in parasites and to evaluate their general health. Material and methods: Inclusions took place at the gold miners’ resting sites, spread along the Maroni river. After recording their informed consent, a malaria rapid test was performed, as well as a questionnaire, a clinical exam and a blood sample for microscopy, PCR and resistance test (RSA and PfK13 genotyping for P. falciparum positive samples). Results: From January to June 2015, 421 gold miners were included, mainly men (sex ratio 2.4), Brazilian nationals (93.8%), with a median age of 37 years. Plasmodium prevalence using PCR was 22.3% (CI95%: 18.3 - 26.3), of whom 84% were asymptomatic. During the last malaria attack, 52.4% selfmedicated with artemisinin derivatives (93.8%) and a poor treatment adherence (37.8%). Being in French Guiana when the malaria attack occurred was strongly associated with selfmedication (AOR=22.1). One sample showed a survival rate higher than 1% in RSA test but PfK13 genotyping did not reveal any mutation in P. falciparum. Discussion: This high prevalence of asymptomatic carriers constitutes a huge reservoir for malaria transmission in the region. Massive use of artemisinin derivatives associated with poor treatment adherence are factors that may contribute to the emergence of artemisinin resistance. That would have huge sanitary and economical consequences. With political will, actions are possible to limit this risk, as the distribution of kits for self diagnosis and self-treatment with training on resting sites.

The introduction of artemisinin-based combination therapy (ACT) substantially reduced malaria-related mortality and morbidity during the past decade. Despite the widespread use of ACT, there is still a considerable knowledge gap with regards to safety, efficacy and pharmacokinetic properties of these drugs, particularly in vulnerable populations like children and pregnant women. In addition, there is growing evidence of widespread artemisinin-resistance across the Greater Mekong Subregion. Expedited delivery of novel antimalarial drugs with different mechanisms of action to the clinical setting is still far off; therefore, it is crucial to improve the use of existing antimalarial drugs for optimal outcome in order to prolong their therapeutic life span. This thesis focuses on utilizing pharmacometric tools to support this effort for malaria prevention and treatment. An extensive simulation framework was used to explore alternative malaria chemopreventive dosing regimens of a commonly used ACT, dihydroartemisinin-piperaquine. Different monthly and weekly dosing regimens were evaluated and this allowed an understanding of the interplay between adherence, loading dose and malaria incidence. A weekly dosing regimen substantially improved the prevention effect and was less impacted by poor adherence. This is also expected to reduce selection pressure for development of resistance to piperaquine. Population pharmacokinetics-pharmacodynamic models were developed for artesunate and the active metabolite dihydroartemisinin, effect on parasite clearance, in patients with artemisinin-resistant and -sensitive malaria infections in Southeast Asia. The modeling identified an association between parasite density and drug bioavailability. It predicted the presence of high levels of artemisinin resistant infection among patients in Cambodia and its spread into Myanmar. A nomogram to identify patients with artemisinin resistant infections was developed. Furthermore, the model was used to demonstrate the need for extended treatment duration to treat patients with artemisinin resistant infections. A population pharmacokinetic model developed from data on pregnant women in East Africa allowed further understanding of artemether-lumefantrine exposure in pregnant populations. It also suggested that the lumefantrine exposure in this population is not compromised. In summary, the results presented in this thesis demonstrate the value of pharmacometric approaches for improving antimalarial drug treatment and prevention. This ultimately contributes to overcoming the prevailing challenges to malaria control.

Magister Public Health - MPH / Malaria is a health, social and economic burden in Nigeria and consistently ranks amongst the four most common causes of childhood deaths. Treatment of malaria is usually started at home; care is only sought from the health facility when the treatment is ineffective (McCombie, 1996). Patent medicine vendors (PMVs) have been identified as a widely patronized source for drugs used in the home treatment of malaria (Breiger et al, 2001; Goodman, et al, 2007; Salako et al, 2001). Inadequate or poor knowledge and practices in the use of anti-malaria drugs (AMDs) increases morbidity and mortality, undermines therapeutic efficacy, and promotes the emergence and spread of drugresistant malaria. Aim: The aim of the study was to describe and quantify the knowledge and self-reported practices of PMVs in the use of antimalarials, particularly artemisinin-based combination therapies (ACTs), in a poor urban community in Lagos state, Nigeria. / South Africa

Each year countless lives are affected and about half a million people die from malaria, a disease caused by parasites originating from the Plasmodium family. The most virulent species of the parasite is Plasmodium falciparum (P. falciparum).   Calmodulin (CaM) is a small, 148 amino acid long, highly preserved and essential protein in all eukaryotic cells. Previous studies have determined that CaM is important for the reproduction and invasion of P. falciparum in host cells. The primary structure of human CaM (CaMhum) and CaM from P. falciparum (CaMpf) differ in merely 16 positions, making differences in their structures and ligand affinity interesting to study. Especially since possible inhibitors of CaMpf in favor of CaMhum, in extension, could give rise to new malaria treatments.   Some antagonists, functioning as inhibitors of CaM, have already been analysed in previous studies. However, there are also compounds that have not yet been studied in regards to being possible antagonists of CaM. This study regards three known antagonists; trifluoperazine (TFP), calmidazolium (CMZ) and artemisinin (ART) and also three recently created fentanyl derivatives; 3-OH-4-OMe-cyclopropylfentanyl (ligand 1), 4-OH-3OMe-4F-isobutyrylfentanyl (ligand 2) and 3-OH-4-OMe-isobutyrylfentanyl (ligand 3).   Bioinformatic methods, such as modelling and docking, were used to compare the structures of CaMhum and CaMpf as well as observe the interaction of the six ligands to CaM from both species. In addition to the differences in primary structure, distinguished with ClustalW, disparities in tertiary structure were observed. Structure analysis of CaMhum and CaMpf in PyMOL disclosed a more open conformation as well as a larger, more defined, hydrophobic cleft in CaMhum compared to CaMpf. Simulated binding of the six ligands to CaM from both species, using Autodock 4.2, indicated that TFP and ART bind with higher affinity to CaMhum which is expected. Ligand 2 and ligand 3 also bound with higher affinity and facilitated stronger binding to CaMhum, which is reasonable since their docking is based on how TFP binds to CaM. However, ligand 1 as well as CMZ both bound to CaMpf with higher affinity. Despite promising results for ligand 1 and CMZ, no decisive conclusion can be made solely based on bioinformatic studies.    To gain a better understanding on the protein-ligand interactions of the six ligands to CaMhum and CaMpf, further studies using e.g. circular dichroism and fluorescence would be advantageous. Based on the results from this study, future studies on the binding of CMZ and ligand 1 to CaM as well as ligands with similar characteristics would be especially valuable. This is because they, based on the results from this study, possibly are better inhibitors of CaMpf than CaMhum and thereby could function as possible antimalarial drugs.

Artemisia annua L. is a well-known medicinal herb used in Traditional Chinese Medicine for many centuries and contains artemisinin, which exhibits antimalarial properties [1] and is a potential treatment for SARS-CoV-2 [2]. However, the neurological effect of A. annua and its compounds are poorly understood. We hypothesize that A. annua extracts and artemisinin will provide protection against oxidative stress in mouse neuronal Neuro2A cells. Superoxide dismutase 1 (SOD1) is an anti-oxidant enzyme that protects against oxidative damage [3]. Growth Arrest and DNA Damage-inducible 45 alpha (Gadd45a) is involved in DNA repair and is a common biomarker for DNA damage[4]. SOD1 and Gadd45a mRNA expression was measured through RT-qPCR and analyzed using the 2-∆∆Ct method. Cell viability was measured using NucBlue, Annexin V, and propidium iodide to differentiate between apoptosis and necrosis. Cell counts were quantified using ImageJ (NIH). Our results showed that lower concentrations of 100 µg/mL A. annua treatment significantly reduced apoptotic cell death during oxidative stress. We also saw a general trend of decreasing Gadd45a mRNA expression at lower concentrations of A. annua treatment and a significant decrease in SOD1 mRNA levels from 0 to 100 µg/mL. This study suggests that lower concentrations of A. annua treatment prior to oxidative stress can increase cell viability and could protect Neuro2A cells from oxidative stress. Further research is needed to elucidate the mechanism of A. annua’s and artemisinin’s medicinal properties and further test their potential neuroprotective effects.

Introduction: Antimalarial resistance, particularly artemisinin resistance, is a major threat to P. falciparum malaria elimination efforts worldwide. Urgent intervention is required to tackle artemisinin resistance but field data on which to base planning of strategies are limited. The aims were to collect available field data and develop population level mathematical models of P. falciparum malaria treatment and artemisinin resistance in order to determine the optimal strategies for elimination of artemisinin resistant malaria in Cambodia and treatment of pre-hospital and severe malaria in Cambodia and Bangladesh. Methods: Malaria incidence and parasite clearance data from Cambodia and Bangladesh were collected and analysed and modelling parameters derived. Population dynamic mathematical models of P. falciparum malaria were produced. Results: The modelling demonstrated that elimination of artemisinin resistant P. falciparum malaria would be achievable in Cambodia in the context of artemisinin resistance using high coverages with ACT treatment, ideally combined with LLITNs and adjunctive single dose primaquine. Sustained efforts would be necessary to achieve elimination and effective surveillance is essential, both to identify the baseline malaria burden and to monitor parasite prevalence as interventions are implemented. A modelled policy change to rectal and intravenous artesunate in the context of pre-existing artemisinin resistance would not compromise the efficacy of ACT for malaria elimination. Conclusions: By being developed rapidly in response to specific questions the models presented here are helping to inform planning efforts to combat artemisinin resistance. As further field data become available, their planned on-going development will produce increasingly realistic and informative models which can be expected to play a central role in planning efforts for years to come.