Antigenic strain diversity predicts different biogeographic patterns of invasion and maintenance of anti-malarial drug resistance

Reviewer #1 (Public Review):

Summary:
The paper is an attempt to explain a geographic paradox between infection prevalence and antimalarial resistance emergence. The authors developed a compartmental model that importantly contains antigenic strain diversity and in turn antigen-specific immunity. They find a negative correlation between parasite prevalence and the frequency of resistance emergence and validate this result using empirical data on chloroquine-resistance. Overall, the authors conclude that strain diversity is a key player in explaining observed patterns of resistance evolution across different geographic regions.

The authors pose and address the following specific questions:

1. Does strain diversity modulate the equilibrium resistance frequency given different transmission intensities?
2. Does strain diversity modulate the equilibrium resistance frequency and its changes following drug withdrawal?
3. Does the model explain biogeographic patterns of drug resistance evolution?

Strengths:
The model built by the authors is novel. As emphasized in the manuscript, many factors (e.g., drug usage, vectorial capacity, population immunity) have been explored in models attempting to explain resistance emergence, but strain diversity (and strain-specific immunity) has not been explicitly included and thus explored. This is an interesting oversight in previous models, given the vast antigenic diversity of Plasmodium falciparum (the most common human malaria parasite) and its potential to "drive key differences in epidemiological features".

The model also accounts for multiple infections, which is a key feature of malarial infections, with individuals often infected with either multiple Plasmodium species or multiple strains of the same species. Accounting for multiple infections is critical when considering resistance emergence, as with multiple infections there is within-host competition which will mediate the fitness of resistant genotypes. Overall, the model is an interesting combination of a classic epidemiological model (e.g., SIR) and a population genetics model.

In terms of major model innovations, the model also directly links selection pressure via drug administration with local transmission dynamics. This is accomplished by the interaction between strain-specific immunity, generalized immunity, and host immune response.

Weaknesses:
In several places, the explanation of the results (i.e., why are we seeing this result?) is underdeveloped. For example, under the section "Response to drug policy change", it is stated that (according to the model) low diversity scenarios show the least decline in resistant genotype frequency after drug withdrawal; however, this result emerges mechanistically. Without an explicit connection to the workings of the model, it can be difficult to gauge whether the result(s) seen are specific to the model itself or likely to be more generalizable.

The authors emphasize several model limitations, including the specification of resistance by a single locus (thus not addressing the importance of recombination should resistance be specified by more than one locus); the assumption that parasites are independently and randomly distributed among hosts (contrary to empirical evidence); and the assumption of a random association between the resistant genotype and antigenic diversity. However, each of these limitations is addressed in the discussion.

Did the authors achieve their goals? Did the results support their conclusion?

Returning to the questions posed by the authors:

1. Does strain diversity modulate the equilibrium resistance frequency given different transmission intensities? Yes. The authors demonstrate a negative relationship between prevalence/strain diversity and resistance frequency (Figure 2).

2. Does strain diversity modulate the equilibrium resistance frequency and its changes following drug withdrawal? Yes. The authors find that, under resistance invasion and some level of drug treatment, resistance frequency decreased with the number of strains (Figure 4). The authors also find that lower strain diversity results in a slower decline in resistant genotypes after drug withdrawal and higher equilibrium resistance frequency (Figure 6).

3. Does the model explain biogeographic patterns of drug resistance evolution? Yes. The authors find that their full model (which includes strain-specific immunity) produces the empirically observed negative relationship between resistance and prevalence/strain diversity, while a model only incorporating generalised immunity does not (Figure 8).

Utility of work to others and relevance within and beyond the field?
This work is important because antimalarial drug resistance has been an ongoing issue of concern for much of the 20th century and now 21st century. Further, this resistance emergence is not equitably distributed across biogeographic regions, with South America and Southeast Asia experiencing much of the burden of this resistance emergence. Not only can widespread resistant strains be traced back to these two relatively low-transmission regions, but these strains remain at high frequency even after drug treatment ceases.

Reviewer #2 (Public Review):

Summary:
The evolution of resistance to antimalarial drugs follows a seemingly counterintuitive pattern, in which resistant strains typically originate in regions where malaria prevalence is relatively low. Previous investigations have suggested that frequent exposures in high-prevalence regions produce high levels of partial immunity in the host population, leading to subclinical infections that go untreated. These subclinical infections serve as refuges for sensitive strains, maintaining them in the population. Prior investigations have supported this hypothesis; however, many of them excluded important dynamics, and the results cannot be generalized. The authors have taken a novel approach using a deterministic model that includes both general and adaptive immunity. They find that high levels of population immunity produce refuges, maintaining the sensitive strains and allowing them to outcompete resistant strains. While general population immunity contributed, adaptive immunity is key to reproducing empirical patterns. These results are robust across a range of fitness costs, treatment rates, and resistance efficacies. They demonstrate that future investigations cannot overlook adaptive immunity and antigenic diversity.

Strengths:
Overall, this is a very nice paper that makes a significant contribution to the field. It is well-framed within the body of literature and achieves its goal of providing a generalizable, unifying explanation for otherwise disparate investigations. As such, this work will likely serve as a foundation for future investigations. The approach is elegant and rigorous, with results that are supported across a broad range of parameters.

Weaknesses:
Although the title states that the authors describe resistance invasion, they do not support or even explore this claim. As they state in the discussion (line 351), this work predicts the equilibrium state and doesn't address temporal patterns. While refuges in partially immune hosts may maintain resistance in a population, they do not account for the patterns of resistance spread, such as the rapid spread of chloroquine resistance in Africa once it was introduced from Asia.

As the authors state in the discussion, the evolution of compensatory mutations that negate the cost of resistance is possible, and in vitro experiments have found evidence of such. It appears that their results are dependent on there being a cost, but the lower range of the cost parameter space was not explored.

The use of a deterministic, compartmental model may be a structural weakness. This means that selection alone guides the fixation of new mutations on a semi-homogenous adaptive landscape. In reality, there are two severe bottlenecks in the transmission cycle of Plasmodium spp., introducing a substantial force of stochasticity via genetic drift. The well-mixed nature of this type of model is also likely to have affected the results. In reality, within-host selection is highly heterogeneous, strains are not found with equal frequency either in the population or within hosts, and there will be some linkage between the strain and a resistance mutation, at least at first. Of course, there is no recourse for that at this stage, but it is something that should be considered in future investigations.

The authors mention the observation that patterns of resistance in high-prevalence Papua New Guinea seem to be more similar to Southeast Asia, perhaps because of the low strain diversity in Papua New Guinea. However, they do not investigate that parameter space here. If they did and were able to replicate that observation, not only would that strengthen this work, it could profoundly shape research to come.