Genomic Surveillance to Tackle Antimalarial and Insecticide Resistance in Malaria Control: A Narrative Review

Abstract

Background: Malaria control depends on the continued efficacy of antimalarial drugs and insecticide-based vector control, both of which are increasingly compromised by the evolving genetic capacity of Plasmodium falciparum and Anopheles mosquitoes to resist these tools. Genomic surveillance offers a faster and more spatially resolved alternative to traditional phenotypic monitoring, which is the focus of this review. Methods: This narrative review was conducted using a systematic search of PubMed/MEDLINE, Scopus, Web of Science, medRxiv, and bioRxiv (2014-2026) for primary studies reporting genomic or molecular surveillance of antimalarial resistance, pfhrp2/pfhrp3 diagnostic-escape deletions, or insecticide resistance, with findings described narratively and grouped by thematic domain. Results: Included studies revealed significant geographical heterogeneity: rising kelch13 markers in East Africa contrasted with their near-absence in southern Africa and Angola, while the Greater Mekong subregion showed an established multidrug-resistant lineage combining kelch13 mutations with plasmepsin2/3 amplification. Pfhrp2/3 diagnostic-escape deletions were spreading under active positive selection in the Horn of Africa. In Anopheles vectors, target-site (kdr/Vgsc) and metabolic (cytochrome P450-mediated) resistance were widespread and often co-occurred within the same populations. Portable, cost-effective sequencing platforms are increasingly enabling downstream, in-country surveillance, although integration into routine decision-making remains uneven. Conclusion: Genomic surveillance is reshaping resistance monitoring, but its public-health value depends on sustained investment in decentralized sequencing capacity, data-sharing infrastructure that respects national data sovereignty, and stronger links between genomic findings and revisions to treatment and vector-control policies.