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Ngasala BE, Chiduo MG, Mmbando BP, Francis FT, Bushukatale S, Makene T, Mandara CI, Ishengoma DS, Kamugisha E, Ahmed M, Mahende MK, Kavishe RA, Muro F, Molteni F, Reaves E, Kitojo C, Greer G, Nyinondi S, Kabula B, Lalji S, Chacky F, Njau RJ, Warsame M, Mohamed A. Efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in mainland Tanzania, 2019. Malar J 2024; 23:101. [PMID: 38594679 PMCID: PMC11005286 DOI: 10.1186/s12936-024-04931-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/04/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Artemisinin-based combination therapy (ACT) has been a major contributor to the substantial reductions in global malaria morbidity and mortality over the last decade. In Tanzania, artemether-lumefantrine (AL) was introduced as the first-line treatment for uncomplicated Plasmodium falciparum malaria in 2006. The World Health Organization (WHO) recommends regular assessment and monitoring of the efficacy of the first-line treatment, specifically considering that artemisinin resistance has been confirmed in the Greater Mekong sub-region. This study's main aim was to assess the efficacy and safety of AL for treating uncomplicated P. falciparum malaria in Tanzania. METHODS This was a single-arm prospective antimalarial drug efficacy trial conducted in four of the eight National Malaria Control Programme (NMCP) sentinel sites in 2019. The trial was carried out in outpatient health facilities in Karume-Mwanza region, Ipinda-Mbeya region, Simbo-Tabora region, and Nagaga-Mtwara region. Children aged six months to 10 years with microscopy confirmed uncomplicated P. falciparum malaria who met the inclusion criteria were recruited based on the WHO protocol. The children received AL (a 6-dose regimen of AL twice daily for three days). Clinical and parasitological parameters were monitored during follow-up over 28 days to evaluate drug efficacy. RESULTS A total of 628 children were screened for uncomplicated malaria, and 349 (55.6%) were enrolled between May and September 2019. Of the enrolled children, 343 (98.3%) completed the 28-day follow-up or attained the treatment outcomes. There were no early treatment failures; recurrent infections during follow-up were common at two sites (Karume 29.5%; Simbo 18.2%). PCR-corrected adequate clinical and parasitological response (ACPR) by survival analysis to AL on day 28 of follow-up varied from 97.7% at Karume to 100% at Ipinda and Nagaga sites. The commonly reported adverse events were cough, skin pallor, and abdominal pain. The drug was well tolerated, and no serious adverse event was reported. CONCLUSION This study showed that AL had adequate efficacy and safety for the treatment of uncomplicated falciparum malaria in Tanzania in 2019. The high recurrent infections were mainly due to new infections, highlighting the potential role of introducing alternative artemisinin-based combinations that offer improved post-treatment prophylaxis, such as artesunate-amodiaquine (ASAQ).
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Affiliation(s)
- Billy E Ngasala
- Department of Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Mercy G Chiduo
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Bruno P Mmbando
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Filbert T Francis
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Samwel Bushukatale
- Department of Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Twilumba Makene
- Department of Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Celine I Mandara
- National Institute for Medical Research, Headquarters, Dar es Salaam, Tanzania
| | - Deus S Ishengoma
- National Institute for Medical Research, Headquarters, Dar es Salaam, Tanzania
| | - Erasmus Kamugisha
- Catholic University of Health and Allied Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | - Maimuna Ahmed
- Catholic University of Health and Allied Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | | | - Reginald A Kavishe
- Kilimanjaro Christian Medical Centre, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Florida Muro
- Kilimanjaro Christian Medical Centre, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Erik Reaves
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Chonge Kitojo
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Dar es Salaam, Tanzania
| | - George Greer
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Dar es Salaam, Tanzania
| | | | | | | | - Frank Chacky
- National Malaria Control Program, Dodoma, Tanzania
| | - Ritha J Njau
- Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | | | - Ally Mohamed
- National Malaria Control Program, Dodoma, Tanzania
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da Silva C, Boene S, Datta D, Rovira-Vallbona E, Aranda-Díaz A, Cisteró P, Hathaway N, Tessema S, Chidimatembue A, Matambisso G, Nhama A, Macete E, Pujol A, Nhamussua L, Galatas B, Guinovart C, Enosse S, De Carvalho E, Rogier E, Plucinski MM, Colborn J, Zulliger R, Saifodine A, Alonso PL, Candrinho B, Greenhouse B, Aide P, Saute F, Mayor A. Targeted and whole-genome sequencing reveal a north-south divide in P. falciparum drug resistance markers and genetic structure in Mozambique. Commun Biol 2023; 6:619. [PMID: 37291425 PMCID: PMC10250372 DOI: 10.1038/s42003-023-04997-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/30/2023] [Indexed: 06/10/2023] Open
Abstract
Mozambique is one of the four African countries which account for over half of all malaria deaths worldwide, yet little is known about the parasite genetic structure in that country. We performed P. falciparum amplicon and whole genome sequencing on 2251 malaria-infected blood samples collected in 2015 and 2018 in seven provinces of Mozambique to genotype antimalarial resistance markers and interrogate parasite population structure using genome-wide microhaplotyes. Here we show that the only resistance-associated markers observed at frequencies above 5% were pfmdr1-184F (59%), pfdhfr-51I/59 R/108 N (99%) and pfdhps-437G/540E (89%). The frequency of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine resistance increased from 80% in 2015 to 89% in 2018 (p < 0.001), with a lower expected heterozygosity and higher relatedness of microhaplotypes surrounding pfdhps mutants than wild-type parasites suggestive of recent selection. pfdhfr/pfdhps quintuple mutants also increased from 72% in the north to 95% in the south (2018; p < 0.001). This resistance gradient was accompanied by a concentration of mutations at pfdhps-436 (17%) in the north, a south-to-north increase in the genetic complexity of P. falciparum infections (p = 0.001) and a microhaplotype signature of regional differentiation. The parasite population structure identified here offers insights to guide antimalarial interventions and epidemiological surveys.
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Affiliation(s)
- Clemente da Silva
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Simone Boene
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Debayan Datta
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Andrés Aranda-Díaz
- EPPIcenter Research Program, Division of HIV, ID, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Pau Cisteró
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Sofonias Tessema
- EPPIcenter Research Program, Division of HIV, ID, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Glória Matambisso
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Abel Nhama
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Arnau Pujol
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Lidia Nhamussua
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Beatriz Galatas
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Sónia Enosse
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Eva De Carvalho
- World Health Organization, WHO Country Office Maputo, Maputo, Mozambique
| | - Eric Rogier
- Malaria Branch, Division of Parasitic Diseases and Malaria, United States Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mateusz M Plucinski
- United States President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, United States Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Colborn
- Clinton Health Access Initiative, Maputo, Mozambique
| | - Rose Zulliger
- U.S. President's Malaria Initiative, USAID, Washington, DC, USA
| | | | - Pedro L Alonso
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Baltazar Candrinho
- National Malaria Control Programme, Ministry of Health, Maputo, Mozambique
| | - Bryan Greenhouse
- EPPIcenter Research Program, Division of HIV, ID, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Francisco Saute
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Alfredo Mayor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
- Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.
- Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.
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3
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Marwa K, Kapesa A, Baraka V, Konje E, Kidenya B, Mukonzo J, Kamugisha E, Swedberg G. Therapeutic efficacy of artemether-lumefantrine, artesunate-amodiaquine and dihydroartemisinin-piperaquine in the treatment of uncomplicated Plasmodium falciparum malaria in Sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2022; 17:e0264339. [PMID: 35271592 PMCID: PMC8912261 DOI: 10.1371/journal.pone.0264339] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background Sub-Saharan Africa has the highest burden of malaria in the world. Artemisinin-based combination therapies (ACTs) have been the cornerstone in the efforts to reduce the global burden of malaria. In the effort to facilitate early detection of resistance for artemisinin derivatives and partner drugs, WHO recommends monitoring of ACT’s efficacy in the malaria endemic countries. The present systematic meta-analysis study summarises the evidence of therapeutic efficacy of the commonly used artemisinin-based combinations for the treatment of uncomplicated P. falciparum malaria in Sub-Saharan Africa after more than a decade since the introduction of the drugs. Methods Fifty two studies carried out from 2010 to 2020 on the efficacy of artemether-lumefantrine or dihydro-artemisinin piperaquine or artesunate amodiaquine in patients with uncomplicated P. falciparum malaria in Sub-Saharan Africa were searched for using the Google Scholar, Cochrane Central Register of controlled trials (CENTRAL), PubMed, Medline, LILACS, and EMBASE online data bases. Data was extracted by two independent reviewers. Random analysis effect was performed in STATA 13. Heterogeneity was established using I2 statistics. Results Based on per protocol analysis, unadjusted cure rates in malaria infected patients treated with artemether-lumefantrine (ALU), artesunate-amodiaquine (ASAQ) and dihydroartemisinin-piperaquine (DHP) were 89%, 94% and 91% respectively. However, the cure rates after PCR correction were 98% for ALU, 99% for ASAQ and 99% for DHP. Conclusion The present meta-analysis reports the overall high malaria treatment success for artemether-lumefantrine, artesunate-amodiaquine and dihydroartemisinin-piperaquine above the WHO threshold value in Sub-Saharan Africa.
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Affiliation(s)
- Karol Marwa
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- * E-mail: ,
| | - Anthony Kapesa
- Department of Community Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Vito Baraka
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Evelyne Konje
- Department of Epidemiology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Benson Kidenya
- Department of Biochemistry, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Jackson Mukonzo
- Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Erasmus Kamugisha
- Department of Biochemistry, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Gote Swedberg
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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4
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Dentinger CM, Rakotomanga TA, Rakotondrandriana A, Rakotoarisoa A, Rason MA, Moriarty LF, Steinhardt LC, Kapesa L, Razafindrakoto J, Svigel SS, Lucchi NW, Udhayakumar V, Halsey ES, Ratsimbasoa CA. Efficacy of artesunate-amodiaquine and artemether-lumefantrine for uncomplicated Plasmodium falciparum malaria in Madagascar, 2018. Malar J 2021; 20:432. [PMID: 34732201 PMCID: PMC8565026 DOI: 10.1186/s12936-021-03935-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/30/2021] [Indexed: 11/12/2022] Open
Abstract
Background Since 2005, artemisinin-based combination therapy (ACT) has been recommended to treat uncomplicated falciparum malaria in Madagascar. Artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) are the first- and second-line treatments, respectively. A therapeutic efficacy study was conducted to assess ACT efficacy and molecular markers of anti-malarial resistance. Methods Children aged six months to 14 years with uncomplicated falciparum malaria and a parasitaemia of 1000–100,000 parasites/µl determined by microscopy were enrolled from May–September 2018 in a 28-day in vivo trial using the 2009 World Health Organization protocol for monitoring anti-malarial efficacy. Participants from two communes, Ankazomborona (tropical, northwest) and Matanga (equatorial, southeast), were randomly assigned to ASAQ or AL arms at their respective sites. PCR correction was achieved by genotyping seven neutral microsatellites in paired pre- and post-treatment samples. Genotyping assays for molecular markers of resistance in the pfk13, pfcrt and pfmdr1 genes were conducted. Results Of 344 patients enrolled, 167/172 (97%) receiving ASAQ and 168/172 (98%) receiving AL completed the study. For ASAQ, the day-28 cumulative PCR-uncorrected efficacy was 100% (95% CI 100–100) and 95% (95% CI 91–100) for Ankazomborona and Matanga, respectively; for AL, it was 99% (95% CI 97–100) in Ankazomborona and 83% (95% CI 76–92) in Matanga. The day-28 cumulative PCR-corrected efficacy for ASAQ was 100% (95% CI 100–100) and 98% (95% CI 95–100) for Ankazomborona and Matanga, respectively; for AL, it was 100% (95% CI 99–100) in Ankazomborona and 95% (95% CI 91–100) in Matanga. Of 83 successfully sequenced samples for pfk13, no mutation associated with artemisinin resistance was observed. A majority of successfully sequenced samples for pfmdr1 carried either the NFD or NYD haplotypes corresponding to codons 86, 184 and 1246. Of 82 successfully sequenced samples for pfcrt, all were wild type at codons 72–76. Conclusion PCR-corrected analysis indicated that ASAQ and AL have therapeutic efficacies above the 90% WHO acceptable cut-off. No genetic evidence of resistance to artemisinin was observed, which is consistent with the clinical outcome data. However, the most common pfmdr1 haplotypes were NYD and NFD, previously associated with tolerance to lumefantrine. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03935-4.
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Affiliation(s)
- Catherine M Dentinger
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia. .,US President's Malaria Initiative, US Centers for Disease Control and Prevention, Antananarivo, Madagascar.
| | - Tovonahary Angelo Rakotomanga
- National Malaria Control Programme, Ministry of Health, Antananarivo, Madagascar.,University of Antananarivo, Antananarivo, Madagascar
| | | | | | - Marie Ange Rason
- National Malaria Control Programme, Ministry of Health, Antananarivo, Madagascar
| | - Leah F Moriarty
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia.,US President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laurent Kapesa
- US President's Malaria Initiative, USAID, Antananarivo, Madagascar
| | | | - Samaly S Svigel
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Naomi W Lucchi
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Venkatachalam Udhayakumar
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric S Halsey
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia.,US President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - C Arsène Ratsimbasoa
- National Malaria Control Programme, Ministry of Health, Antananarivo, Madagascar.,University of Fianarantsoa, Fianarantsoa, Madagascar.,Centre National d' Application de Recherche Pharmaceutique, Antananarivo, Madagascar
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5
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Chidimatembue A, Svigel SS, Mayor A, Aíde P, Nhama A, Nhamussua L, Nhacolo A, Bassat Q, Salvador C, Enosse S, Saifodine A, De Carvalho E, Candrinho B, Zulliger R, Goldman I, Udhayakumar V, Lucchi NW, Halsey ES, Macete E. Molecular surveillance for polymorphisms associated with artemisinin-based combination therapy resistance in Plasmodium falciparum isolates collected in Mozambique, 2018. Malar J 2021; 20:398. [PMID: 34641867 PMCID: PMC8507114 DOI: 10.1186/s12936-021-03930-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Due to the threat of emerging anti-malarial resistance, the World Health Organization recommends incorporating surveillance for molecular markers of anti-malarial resistance into routine therapeutic efficacy studies (TESs). In 2018, a TES of artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) was conducted in Mozambique, and the prevalence of polymorphisms in the pfk13, pfcrt, and pfmdr1 genes associated with drug resistance was investigated. Methods Children aged 6–59 months were enrolled in four study sites. Blood was collected and dried on filter paper from participants who developed fever within 28 days of initial malaria treatment. All samples were first screened for Plasmodium falciparum using a multiplex real-time PCR assay, and polymorphisms in the pfk13, pfcrt, and pfmdr1 genes were investigated by Sanger sequencing. Results No pfk13 mutations, associated with artemisinin partial resistance, were observed. The only pfcrt haplotype observed was the wild type CVMNK (codons 72–76), associated with chloroquine sensitivity. Polymorphisms in pfmdr1 were only observed at codon 184, with the mutant 184F in 43/109 (39.4%) of the samples, wild type Y184 in 42/109 (38.5%), and mixed 184F/Y in 24/109 (22.0%). All samples possessed N86 and D1246 at these two codons. Conclusion In 2018, no markers of artemisinin resistance were documented. Molecular surveillance should continue to monitor the prevalence of these markers to inform decisions on malaria treatment in Mozambique.
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Affiliation(s)
| | - Samaly S Svigel
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfredo Mayor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Pedro Aíde
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Abel Nhama
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Lídia Nhamussua
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Arsénio Nhacolo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Crizólgo Salvador
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Sónia Enosse
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Abuchahama Saifodine
- United States President's Malaria Initiative, US Agency for International Development, Maputo, Mozambique
| | | | - Baltazar Candrinho
- National Malaria Control Programme, Ministry of Health, Maputo, Mozambique
| | - Rose Zulliger
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.,United States President's Malaria Initiative, Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Ira Goldman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Venkatachalam Udhayakumar
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Naomi W Lucchi
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eric S Halsey
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.,United States President's Malaria Initiative, Atlanta, GA, USA
| | - Eusébio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique. .,National Directorate of Public Health, Ministry of Health, Maputo, Mozambique.
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6
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Nhama A, Nhamússua L, Macete E, Bassat Q, Salvador C, Enosse S, Candrinho B, Carvalho E, Nhacolo A, Chidimatembue A, Saifodine A, Zulliger R, Lucchi N, Svigel SS, Moriarty LF, Halsey ES, Mayor A, Aide P. In vivo efficacy and safety of artemether-lumefantrine and amodiaquine-artesunate for uncomplicated Plasmodium falciparum malaria in Mozambique, 2018. Malar J 2021; 20:390. [PMID: 34600544 PMCID: PMC8487544 DOI: 10.1186/s12936-021-03922-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT) has been the recommended first-line treatment for uncomplicated malaria in Mozambique since 2006, with artemether–lumefantrine (AL) and amodiaquine–artesunate (AS–AQ) as the first choice. To assess efficacy of currently used ACT, an in vivo therapeutic efficacy study was conducted. Methods The study was conducted in four sentinel sites: Montepuez, Moatize, Mopeia and Massinga. Patients between 6 and 59 months old with uncomplicated Plasmodium falciparum malaria (2000–200,000 parasites/µl) were enrolled between February and September of 2018, assigned to either an AL or AS–AQ treatment arm, and monitored for 28 days. A Bayesian algorithm was applied to differentiate recrudescence from new infection using genotyping data of seven neutral microsatellites. Uncorrected and PCR-corrected efficacy results at day 28 were calculated. Results Totals of 368 and 273 patients were enrolled in the AL and AS–AQ arms, respectively. Of these, 9.5% (35/368) and 5.1% (14/273) were lost to follow-up in the AL and AS–AQ arms, respectively. There were 48 and 3 recurrent malaria infections (late clinical and late parasitological failures) in the AL and AS–AQ arms, respectively. The day 28 uncorrected efficacy was 85.6% (95% confidence interval (CI) 81.3–89.2%) for AL and 98.8% (95% CI 96.7–99.8%) for AS–AQ, whereas day 28 PCR-corrected efficacy was 97.9% (95% CI 95.6–99.2%) for AL and 99.6% (95% CI 97.9–100%) for AS–AQ. Molecular testing confirmed that 87.4% (42/48) and 33.3% (1/3) of participants with a recurrent malaria infection in the AL and AS–AQ arms were new infections; an expected finding in a high malaria transmission area. Adverse events were documented in less than 2% of participants for both drugs. Conclusion Both AL and AS–AQ have therapeutic efficacies well above the 90% WHO recommended threshold and remain well-tolerated in Mozambique. Routine monitoring of therapeutic efficacy should continue to ensure the treatments remain efficacious. Trial registration Clinicaltrials.gov: NCT04370977 Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03922-9.
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Affiliation(s)
- Abel Nhama
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Lídia Nhamússua
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Eusébio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Direção Nacional de Saúde Pública, Ministério da Saúde, Maputo, Mozambique
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Crizolgo Salvador
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Sónia Enosse
- Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique
| | - Baltazar Candrinho
- Programa Nacional de Controlo da Malária, Ministério da Saúde, Maputo, Mozambique
| | - Eva Carvalho
- World Health Organization, WHO Country Office Maputo, Maputo, Mozambique
| | - Arsénio Nhacolo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | - Abuchahama Saifodine
- United States President's Malaria Initiative, United States Agency for International Development, Maputo, Mozambique
| | - Rose Zulliger
- United States President's Malaria Initiative, Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Naomi Lucchi
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Samaly S Svigel
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Leah F Moriarty
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.,United States President's Malaria Initiative, Atlanta, GA, USA
| | - Eric S Halsey
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.,United States President's Malaria Initiative, Atlanta, GA, USA
| | - Alfredo Mayor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique. .,Instituto Nacional de Saúde (INS), Ministério da Saúde, Maputo, Mozambique.
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7
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Therapeutic Efficacy of Artemether-Lumefantrine (Coartem®) for the Treatment of Uncomplicated Falciparum Malaria in Africa: A Systematic Review. J Parasitol Res 2020; 2020:7371681. [PMID: 33145101 PMCID: PMC7599419 DOI: 10.1155/2020/7371681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/09/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Africa still bears the largest burden of malaria as the majority of infections in the continent are caused by P. falciparum. Artemether-lumefantrine (AL, Coartem®) is the most widely used artemisinin-based combination therapy (ACT), for treating uncomplicated falciparum malaria globally. However, the development of resistance to antimalarial drugs is a major challenge for malaria control. In this review, the efficacy of AL for the treatment of uncomplicated falciparum malaria in Africa was evaluated. Methods Articles published between January 2015 and July 2019 were systematically searched using comprehensive search strings from PubMed/Medline, SCOPUS, and grey literature from Google Scholar. Interventional studies that followed patients for at least 28 days were included. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. All the included articles were measured to be good quality. While computing the efficacy of AL, polymerase chain reaction (PCR)–corrected cure rate (adequate clinical and parasitological response, ACPR) at day 28 was considered as the main endpoint. Meta-analysis was computed using STATA v 15 to calculate the pooled ACPR. Results In this review, 39 articles that reported the treatment outcome of 8,320 patients were included. After 28 days of follow-up, the pooled PCR uncorrected and corrected APCR was at 87% (95% CI: 85-90%) and 97.0% (95% CI: 96-98%), respectively. Moreover, the proportion of early treatment failure (ETF) was almost 0%, while most of the included articles reported <8% late treatment failures. The reinfection and recrudescence rate was less than 10% and 2.6%, respectively, within 28 days. We noted rapid fever and parasite clearance in which greater than 93% and 94% patients were parasite and fever free at day three following AL treatment. Conclusions This review discovered that despite more than a decade since its introduction, Coartem® remains effective and thus could continue to be the drug of choice for the treatment of uncomplicated falciparum malaria for all age groups in Africa. However, the risk of new emerging resistance for this combination warrants regular monitoring of its efficacy across the continent.
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8
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Galatas B, Saúte F, Martí-Soler H, Guinovart C, Nhamussua L, Simone W, Munguambe H, Hamido C, Montañà J, Muguande O, Maartens F, Luis F, Paaijmans K, Mayor A, Bassat Q, Menéndez C, Macete E, Rabinovich R, Alonso PL, Candrinho B, Aide P. A multiphase program for malaria elimination in southern Mozambique (the Magude project): A before-after study. PLoS Med 2020; 17:e1003227. [PMID: 32797101 PMCID: PMC7428052 DOI: 10.1371/journal.pmed.1003227] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/17/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Malaria eradication remains the long-term vision of the World Health Organization (WHO). However, whether malaria elimination is feasible in areas of stable transmission in sub-Saharan Africa with currently available tools remains a subject of debate. This study aimed to evaluate a multiphased malaria elimination project to interrupt Plasmodium falciparum malaria transmission in a rural district of southern Mozambique. METHODS AND FINDINGS A before-after study was conducted between 2015 and 2018 in the district of Magude, with 48,448 residents living in 10,965 households. Building on an enhanced surveillance system, two rounds of mass drug administrations (MDAs) per year over two years (phase I, August 2015-2017), followed by one year of reactive focal mass drug administrations (rfMDAs) (phase II, September 2017-June 2018) were deployed with annual indoor residual spraying (IRS), programmatically distributed long-lasting insecticidal nets (LLINs), and standard case management. The four MDA rounds covered 58%-72% of the population, and annual IRS reported coverage was >70%. Yearly parasite surveys and routine surveillance data were used to monitor the primary outcomes of the study-malaria prevalence and incidence-at baseline and annually since the onset of the project. Parasite prevalence by rapid diagnostic test (RDT) declined from 9.1% (95% confidence interval [CI] 7.0-11.8) in May 2015 to 2.6% (95% CI 2.0-3.4), representing a 71.3% (95% CI 71.1-71.4, p < 0.001) reduction after phase I, and to 1.4% (95% CI 0.9-2.2) after phase II. This represented an 84.7% (95% CI 81.4-87.4, p < 0.001) overall reduction in all-age prevalence. Case incidence fell from 195 to 75 cases per 1,000 during phase I (61.5% reduction) and to 67 per 1,000 during phase II (65.6% overall reduction). Interrupted time series (ITS) analysis was used to estimate the level and trend change in malaria cases associated with the set of project interventions and the number of cases averted. Phase I interventions were associated with a significant immediate reduction in cases of 69.1% (95% CI 57.5-77.6, p < 0.001). Phase II interventions were not associated with a level or trend change. An estimated 76.7% of expected cases were averted throughout the project (38,369 cases averted of 50,005 expected). One malaria-associated inpatient death was observed during the study period. There were 277 mild adverse events (AEs) recorded through the passive pharmacovigilance system during the four MDA rounds. One serious adverse event (SAE) that resulted in death was potentially related to the drug. The study was limited by the incomplete coverage of interventions, the quality of the routine and cross-sectional data collected, and the restricted accuracy of ITS analysis with a short pre-intervention period. CONCLUSION In this study, we observed that the interventions deployed during the Magude project fell short of interrupting P. falciparum transmission with the coverages achieved. While new tools and strategies may be required to eventually achieve malaria elimination in stable transmission areas of sub-Saharan Africa, this project showed that innovative mixes of interventions can achieve large reductions in disease burden, a necessary step in the pathway towards elimination. TRIAL REGISTRATION ClinicalTrials.gov NCT02914145.
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Affiliation(s)
- Beatriz Galatas
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- * E-mail:
| | - Francisco Saúte
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | | | - Lidia Nhamussua
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Wilson Simone
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Camilo Hamido
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Júlia Montañà
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Olinda Muguande
- Fundação para o Desenvolvimento da Comunidade, Maputo, Mozambique
| | | | - Fabião Luis
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Krijn Paaijmans
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- School of Life Sciences, Center for Evolution and Medicine, Biodesign Center for Immunotherapy, Vaccines and Virotherapy, Arizona State University, Tempe, United States of America
| | - Alfredo Mayor
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Quique Bassat
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
| | - Clara Menéndez
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- National Institute of Health, Ministry of Health, Maputo, Mozambique
| | - Regina Rabinovich
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Pedro L. Alonso
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Baltazar Candrinho
- National Malaria Control Program, Ministry of Health, Maputo, Mozambique
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- National Institute of Health, Ministry of Health, Maputo, Mozambique
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9
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Improving Methods for Analyzing Antimalarial Drug Efficacy Trials: Molecular Correction Based on Length-Polymorphic Markers msp-1, msp-2, and glurp. Antimicrob Agents Chemother 2019; 63:AAC.00590-19. [PMID: 31307982 PMCID: PMC6709465 DOI: 10.1128/aac.00590-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/02/2019] [Indexed: 01/14/2023] Open
Abstract
Drug efficacy trials monitor the continued efficacy of front-line drugs against falciparum malaria. Overestimating efficacy results in a country retaining a failing drug as first-line treatment with associated increases in morbidity and mortality, while underestimating drug effectiveness leads to removal of an effective treatment with substantial practical and economic implications. Drug efficacy trials monitor the continued efficacy of front-line drugs against falciparum malaria. Overestimating efficacy results in a country retaining a failing drug as first-line treatment with associated increases in morbidity and mortality, while underestimating drug effectiveness leads to removal of an effective treatment with substantial practical and economic implications. Trials are challenging: they require long durations of follow-up to detect drug failures, and patients are frequently reinfected during that period. Molecular correction based on parasite genotypes distinguishes reinfections from drug failures to ensure the accuracy of failure rate estimates. Several molecular correction “algorithms” have been proposed, but which is most accurate and/or robust remains unknown. We used pharmacological modeling to simulate parasite dynamics and genetic signals that occur in patients enrolled in malaria drug clinical trials. We compared estimates of treatment failure obtained from a selection of proposed molecular correction algorithms against the known “true” failure rate in the model. Our findings are as follows. (i) Molecular correction is essential to avoid substantial overestimates of drug failure rates. (ii) The current WHO-recommended algorithm consistently underestimates the true failure rate. (iii) Newly proposed algorithms produce more accurate failure rate estimates; the most accurate algorithm depends on the choice of drug, trial follow-up length, and transmission intensity. (iv) Long durations of patient follow-up may be counterproductive; large numbers of new infections accumulate and may be misclassified, overestimating drug failure rate. (v) Our model was highly consistent with existing in vivo data. The current WHO-recommended method for molecular correction and analysis of clinical trials should be reevaluated and updated.
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10
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Warsame M, Hassan AM, Hassan AH, Jibril AM, Khim N, Arale AM, Gomey AH, Nur ZS, Osman SM, Mohamed MS, Abdulrahman A, Yusuf FE, Amran JGH, Witkowski B, Ringwald P. High therapeutic efficacy of artemether-lumefantrine and dihydroartemisinin-piperaquine for the treatment of uncomplicated falciparum malaria in Somalia. Malar J 2019; 18:231. [PMID: 31296223 PMCID: PMC6624891 DOI: 10.1186/s12936-019-2864-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/03/2019] [Indexed: 11/26/2022] Open
Abstract
Background Artemether–lumefantrine (AL) and dihydroartemisinin–piperaquine (DHA/PPQ) are the recommended first- and second-line treatments, respectively, for uncomplicated falciparum malaria in Somalia. The studies reported here were conducted to assess the efficacy of these artemisinin-based combinations and the mutations in Plasmodium falciparum K13-propeller (Pfk13) domain and amplification in Pfplasmepsin 2 (Pfpm2) gene in Somalia. Methods One-arm prospective studies were conducted to assess the clinical and parasitological responses to DHA/PPQ and AL at two sites in 2016 and 2017, respectively, using the standard WHO protocol. The patterns of molecular markers associated with artemisinin and PPQ resistance were investigated for the first time in Somalia. Results A total of 339 patients were enrolled with 139 for AL and 200 for DHA/PPQ. With AL, no parasite recurrence was observed among patients treated at either site, corresponding to 100% clinical and parasitological responses. For DHA–PPQ, an adequate clinical and parasitological response rate > 97% was observed. All study patients on both treatments at both sites were parasite-free on day 3. Of the 138 samples with interpretable results for the polymorphism in Pfk13, only one (0.7%), from Bosaso, contained a non-synonymous mutation (R622I), which is not one of the known markers of artemisinin resistance. No Pfpm2 amplification was observed among the 135 samples with interpretable results. Conclusions AL and DHA/PPQ were highly effective in the treatment of uncomplicated falciparum malaria, and there was no evidence of resistance to artemisinin or PPQ. These two combinations are thus relevant in the chemotherapeutic strategy for malaria control in Somalia. Trial registration ACTRN12616001005448 (Jowhar DP study), ACTRN12616000553471 (Bosaso DP study), ACTRN12617001055392 (AL study in Bosaso and Jowhar)
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Affiliation(s)
- Marian Warsame
- Global Malaria Programme, World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland. .,University of Gothenburg, Gothenburg, Sweden.
| | | | | | | | - Nimol Khim
- Malaria Molecular Epidemiology Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | | | | | | | | | | | | | | | | | - Benoit Witkowski
- Malaria Molecular Epidemiology Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia.,Malaria Translational Research Unit, Pasteur Institute, Paris, France
| | - Pascal Ringwald
- Global Malaria Programme, World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
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11
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Gupta H, Macete E, Bulo H, Salvador C, Warsame M, Carvalho E, Ménard D, Ringwald P, Bassat Q, Enosse S, Mayor A. Drug-Resistant Polymorphisms and Copy Numbers in Plasmodium falciparum, Mozambique, 2015. Emerg Infect Dis 2018; 24:40-48. [PMID: 29260689 PMCID: PMC5749434 DOI: 10.3201/eid2401.170864] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
One of the fundamental steps toward malaria control is the use of antimalarial drugs. The success of antimalarial treatment can be affected by the presence of drug-resistant populations of Plasmodium falciparum. To assess resistance, we used molecular methods to examine 351 P. falciparum isolates collected from 4 sentinel sites in Mozambique for K13, pfmdr1, pfcrt, and pfdhps polymorphisms and for plasmepsin2 (pfpm2) and pfmdr1 copy numbers. We found multiple copies of pfpm2 in 1.1% of isolates. All isolates carried K13 wild-type alleles (3D7-like), except 4 novel polymorphisms (Leu619Leu, Phe656Ile, Val666Val, Gly690Gly). Prevalence of isolates with pfcrt mutant (K76T) allele was low (2.3%). Prevalence of isolates with pfdhps mutant alleles (A437G and K540E) was >80%, indicating persistence of sulfadoxine/pyrimethamine resistance; however, markers of artemisinin were absent, and markers of piperaquine resistance were low. Piperaquine resistance isolates may spread in Mozambique as dihydroartemisinin/piperaquine drug pressure increases.
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12
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Dharmawardena P, Rodrigo C, Mendis K, de A. W. Gunasekera WMKT, Premaratne R, Ringwald P, Fernando D. Response of imported malaria patients to antimalarial medicines in Sri Lanka following malaria elimination. PLoS One 2017; 12:e0188613. [PMID: 29182619 PMCID: PMC5705151 DOI: 10.1371/journal.pone.0188613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/12/2017] [Indexed: 11/25/2022] Open
Abstract
After eliminating local malaria transmission and being certified as a malaria-free country, Sri Lanka is facing the challenge of imported malaria. At the same time, the country has the unique opportunity to be a case study for other countries in a similar situation by approaching this issue systematically, guided by evidence. This study demonstrates the importance of developing a mechanism to detect imported malaria and adopting an evidence-based approach to study the resistance of imported malaria to anti-malarial medicines. This is a prospective study of patients diagnosed with imported malaria in Sri Lanka and treated according to the national treatment guidelines, over 24 months (2015/2016). The clinical features, time to diagnosis, origin of the infection, infecting species, parasite density and the treatment given were recorded. All patients were followed up for 28 days, and in the case of Plasmodium vivax and P. ovale infections, the follow up period was extended to 12 months to establish treatment failures and relapses. Fifty nine uncomplicated and 15 severe imported malaria cases were reported in Sri Lanka during the study period. Most of these infections originated in either Sub-Saharan Africa or South and Southeast Asia. Having a P. vivax infection and low parasitic counts were significantly associated with relative diagnostic delay. One of the 14 uncomplicated P. falciparum patients and two of the 12 severe P. falciparum malaria patients who were followed up till day 28 had a late clinical failure. The others responded adequately to treatment both clinically and parasitologically. There was no treatment failure reported amongst any other species. This study, which is the first to assess the therapeutic response of imported malaria in Sri Lanka after elimination, demonstrates that the current antimalarial treatment policies and strategies in Sri Lanka have been effective against infections acquired overseas up until the end of year 2016.
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Affiliation(s)
| | - Chaturaka Rodrigo
- Department of Pathology, School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Kamini Mendis
- Former Coordinator of the Global Malaria Program, World Health Organization, Colombo, Sri Lanka
| | | | | | | | - Deepika Fernando
- Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- * E-mail:
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