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Rosenthal PJ, Asua V, Conrad MD. Emergence, transmission dynamics and mechanisms of artemisinin partial resistance in malaria parasites in Africa. Nat Rev Microbiol 2024; 22:373-384. [PMID: 38321292 DOI: 10.1038/s41579-024-01008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
Malaria, mostly due to Plasmodium falciparum infection in Africa, remains one of the most important infectious diseases in the world. Standard treatment for uncomplicated P. falciparum malaria is artemisinin-based combination therapy (ACT), which includes a rapid-acting artemisinin derivative plus a longer-acting partner drug, and standard therapy for severe P. falciparum malaria is intravenous artesunate. The efficacy of artemisinins and ACT has been threatened by the emergence of artemisinin partial resistance in Southeast Asia, mediated principally by mutations in the P. falciparum Kelch 13 (K13) protein. High ACT treatment failure rates have occurred when resistance to partner drugs is also seen. Recently, artemisinin partial resistance has emerged in Rwanda, Uganda and the Horn of Africa, with independent emergences of different K13 mutants in each region. In this Review, we summarize our current knowledge of artemisinin partial resistance and focus on the emergence of resistance in Africa, including its epidemiology, transmission dynamics and mechanisms. At present, the clinical impact of emerging resistance in Africa is unclear and most available evidence suggests that the efficacies of leading ACTs remain excellent, but there is an urgent need to better appreciate the extent of the problem and its consequences for the treatment and control of malaria.
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Affiliation(s)
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda
- University of Tübingen, Tübingen, Germany
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Rosenthal PJ, Asua V, Bailey JA, Conrad MD, Ishengoma DS, Kamya MR, Rasmussen C, Tadesse FG, Uwimana A, Fidock DA. The emergence of artemisinin partial resistance in Africa: how do we respond? THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00141-5. [PMID: 38552654 DOI: 10.1016/s1473-3099(24)00141-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 04/21/2024]
Abstract
Malaria remains one of the most important infectious diseases in the world, with the greatest burden in sub-Saharan Africa, primarily from Plasmodium falciparum infection. The treatment and control of malaria is challenged by resistance to most available drugs, but partial resistance to artemisinins (ART-R), the most important class for the treatment of malaria, was until recently confined to southeast Asia. This situation has changed, with the emergence of ART-R in multiple countries in eastern Africa. ART-R is mediated primarily by single point mutations in the P falciparum kelch13 protein, with several mutations present in African parasites that are now validated resistance mediators based on clinical and laboratory criteria. Major priorities at present are the expansion of genomic surveillance for ART-R mutations across the continent, more frequent testing of the efficacies of artemisinin-based regimens against uncomplicated and severe malaria in trials, more regular assessment of ex-vivo antimalarial drug susceptibilities, consideration of changes in treatment policy to deter the spread of ART-R, and accelerated development of new antimalarial regimens to overcome the impacts of ART-R. The emergence of ART-R in Africa is an urgent concern, and it is essential that we increase efforts to characterise its spread and mitigate its impact.
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Affiliation(s)
- Philip J Rosenthal
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda; University of Tübingen, Tübingen, Germany
| | - Jeffrey A Bailey
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA; Departments of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Melissa D Conrad
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania; Department of Biochemistry, Kampala International University in Tanzania, Dar es Salaam, Tanzania; School of Public Health, Harvard University, Boston, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Fitsum G Tadesse
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia; London School of Hygiene and Tropical Medicine, London, UK
| | - Aline Uwimana
- Rwanda Biomedical Center, Kigali, Rwanda; Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - David A Fidock
- Department of Microbiology and Immunology and Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Zhao W, Li X, Yang Q, Zhou L, Duan M, Pan M, Qin Y, Li X, Wang X, Zeng W, Zhao H, Sun K, Zhu W, Afrane Y, Amoah LE, Abuaku B, Duah-Quashie NO, Huang Y, Cui L, Yang Z. In vitro susceptibility profile of Plasmodium falciparum clinical isolates from Ghana to antimalarial drugs and polymorphisms in resistance markers. Front Cell Infect Microbiol 2022; 12:1015957. [PMID: 36310880 PMCID: PMC9614232 DOI: 10.3389/fcimb.2022.1015957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/28/2022] [Indexed: 11/21/2022] Open
Abstract
Drug resistance in Plasmodium falciparum compromises the effectiveness of antimalarial therapy. This study aimed to evaluate the extent of drug resistance in parasites obtained from international travelers returning from Ghana to guide the management of malaria cases. Eighty-two clinical parasite isolates were obtained from patients returning from Ghana in 2016–2018, of which 29 were adapted to continuous in vitro culture. Their geometric mean IC50 values to a panel of 11 antimalarial drugs, assessed using the standard SYBR Green-I drug sensitivity assay, were 2.1, 3.8, 1.0, 2.7, 17.2, 4.6, 8.3, 8.3, 19.6, 55.1, and 11,555 nM for artemether, artesunate, dihydroartemisinin, lumefantrine, mefloquine, piperaquine, naphthoquine, pyronaridine, chloroquine, quinine, and pyrimethamine, respectively. Except for chloroquine and pyrimethamine, the IC50 values for other tested drugs were below the resistance threshold. The mean ring-stage survival assay value was 0.8%, with four isolates exceeding 1%. The mean piperaquine survival assay value was 2.1%, all below 10%. Mutations associated with chloroquine resistance (pfcrt K76T and pfmdr1 N86Y) were scarce, consistent with the discontinuation of chloroquine a decade ago. Instead, the pfmdr1 86N-184F-1246D haplotype was predominant, suggesting selection by the extensive use of artemether-lumefantrine. No mutations in the pfk13 propeller domain were detected. The pfdhfr/pfdhps quadruple mutant IRNGK associated with resistance to sulfadoxine-pyrimethamine reached an 82% prevalence. In addition, five isolates had pfgch1 gene amplification but, intriguingly, increased susceptibilities to pyrimethamine. This study showed that parasites originating from Ghana were susceptible to artemisinins and the partner drugs of artemisinin-based combination therapies. Genotyping drug resistance genes identified the signature of selection by artemether-lumefantrine. Parasites showed substantial levels of resistance to the antifolate drugs. Continuous resistance surveillance is necessary to guide timely changes in drug policy.
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Affiliation(s)
- Wei Zhao
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Xinxin Li
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Qi Yang
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Longcan Zhou
- Department of Infectious Diseases, Shanglin County People’s Hospital, Guangxi, China
| | - Mengxi Duan
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Maohua Pan
- Department of Infectious Diseases, Shanglin County People’s Hospital, Guangxi, China
| | - Yucheng Qin
- Department of Infectious Diseases, Shanglin County People’s Hospital, Guangxi, China
| | - Xiaosong Li
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Xun Wang
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Weilin Zeng
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Hui Zhao
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Kemin Sun
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Wenya Zhu
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
| | - Yaw Afrane
- Department of Medical Microbiology, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Linda Eva Amoah
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Benjamin Abuaku
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Nancy Odurowah Duah-Quashie
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Yaming Huang
- Department of Protozoan Diseases, Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, China
| | - Liwang Cui
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
- *Correspondence: Zhaoqing Yang, ; Liwang Cui,
| | - Zhaoqing Yang
- Department of Pathogen Biology and Immunology, Kunming Medical University, Kunming, China
- *Correspondence: Zhaoqing Yang, ; Liwang Cui,
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Doumbia S, Toure M, Sogoba N, Alifrangis M, Diakite M, Diarra A, Keita M, Konaté D, Diawara SI, Thiam SM, Keita S, Tounkara M, Cissé I, Sanogo V, Magassa MH, Barry AE, Winch PJ, Marker HC, Shaffer JG, Traoré SF, Müller GC, Cui L, Beier JC, Mihigo J. The West Africa ICEMR Partnerships for Guiding Policy to Improve the Malaria Prevention and Control. Am J Trop Med Hyg 2022; 107:84-89. [PMID: 36228908 PMCID: PMC9662222 DOI: 10.4269/ajtmh.21-1330] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/06/2022] [Indexed: 12/01/2022] Open
Abstract
The Mali National Malaria Control Program (NMCP) recently established a phased set of goals for eliminating malaria in Mali by 2030. Over the past decade, the scale-up of NMCP-led malaria control interventions has led to considerable progress, as evidenced by multiple malariometric indicators. The West Africa International Center of Excellence in Malaria Research (WA-ICEMR) is a multidisciplinary research program that works closely with the NMCP and its partners to address critical research needs for malaria control. This coordinated effort includes assessing the effectiveness of control interventions based on key malaria research topics, including immune status, parasite genetic diversity, insecticide and drug resistance, diagnostic accuracy, malaria vector populations and biting behaviors, and vectorial capacity. Several signature accomplishments of the WA-ICEMR include identifying changing malaria age demographic profiles, testing innovative approaches to improve control strategies, and providing regular reporting on drug and insecticide resistance status. The NMCP and WA-ICEMR partnership between the WA-ICEMR and the NMCP offers a comprehensive research platform that informs the design and implementation of malaria prevention and control research programs. These efforts build local expertise and capacity for the next generation of malaria researchers and guide local policy, which is crucial in sustaining efforts toward eliminating malaria in West Africa.
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Affiliation(s)
- Seydou Doumbia
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Mahamoudou Toure
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Nafomon Sogoba
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Mahamadou Diakite
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Ayouba Diarra
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Moussa Keita
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Drissa Konaté
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sory I. Diawara
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sidibé M’Baye Thiam
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Soumba Keita
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Moctar Tounkara
- Department of Public Health, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Idrissa Cissé
- National Malaria Control Program, Ministry of Health, Bamako, Mali
| | - Vincent Sanogo
- National Malaria Control Program, Ministry of Health, Bamako, Mali
| | | | | | - Peter J. Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Hannah C. Marker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey G. Shaffer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Sékou F. Traoré
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Günter C. Müller
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Liwang Cui
- Division of Infectious Diseases and Internal Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
| | - John C. Beier
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Jules Mihigo
- U.S. President’s Malaria Initiative, United States Agency for International Development Office, Bamako, Mali
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Doumbia S, Sogoba N, Diakite M, Toure M, Keita M, Konaté D, Diawara SI, Diarra A, Sanogo D, Kane F, Diakite SAS, Traore K, Thiam SM, Traoré SF, Cisse I, Mihigo J, Coulibaly MB, Dabitao D, Alifrangis M, Barry AE, Müller GC, Beier JC, Shaffer JG. A Decade of Progress Accelerating Malaria Control in Mali: Evidence from the West Africa International Center of Excellence for Malaria Research. Am J Trop Med Hyg 2022; 107:75-83. [PMID: 36228923 PMCID: PMC9662231 DOI: 10.4269/ajtmh.21-1309] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/06/2022] [Indexed: 11/07/2022] Open
Abstract
This article highlights over a decade of signature achievements by the West Africa International Centers for Excellence in Malaria Research (WA-ICEMR) and its partners toward guiding malaria prevention and control strategies. Since 2010, the WA-ICEMR has performed longitudinal studies to monitor and assess malaria control interventions with respect to space-time patterns, vector transmission indicators, and drug resistance markers. These activities were facilitated and supported by the Mali National Malaria Control Program. Research activities included large-scale active and passive surveillance and expanded coverage of universal long-lasting insecticide-treated bed nets and seasonal malaria chemoprevention (SMC). The findings revealed substantial declines in malaria occurrence after the scale-up of control interventions in WA-ICEMR study sites. WA-ICEMR studies showed that SMC using sulfadoxine-pyrimethamine plus amodiaquine was highly effective in preventing malaria among children under 5 years of age. An alternative SMC regimen (dihydroartemisinin plus piperaquine) was shown to be potentially more effective and provided advantages for acceptability and compliance over the standard SMC regimen. Other findings discussed in this article include higher observed multiplicity of infection rates for malaria in historically high-endemic areas, continued antimalarial drug sensitivity to Plasmodium falciparum, high outdoor malaria transmission rates, and increased insecticide resistance over the past decade. The progress achieved by the WA-ICEMR and its partners highlights the critical need for maintaining current malaria control interventions while developing novel strategies to disrupt malaria transmission. Enhanced evaluation of these strategies through research partnerships is particularly needed in the wake of reported artemisinin resistance in Southeast Asia and East Africa.
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Affiliation(s)
- Seydou Doumbia
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Nafomon Sogoba
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Mahamadou Diakite
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Mahamoudou Toure
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Moussa Keita
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Drissa Konaté
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sory I. Diawara
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Ayouba Diarra
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Daouda Sanogo
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Fousseyni Kane
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Seidina A. S. Diakite
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Karim Traore
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sidibé M’Baye Thiam
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sékou F. Traoré
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Idrissa Cisse
- National Malaria Control Program, Ministry of Health, Bamako, Mali
| | - Jules Mihigo
- U.S. President’s Malaria Initiative, United States Agency for International Development Office, Bamako, Mali
| | - Mamadou B. Coulibaly
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Djeneba Dabitao
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | | | - Günter C. Müller
- Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
- University Clinical Research Center, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - John C. Beier
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Jeffrey G. Shaffer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
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