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Woldesenbet D, Birhanie M, Abere A, Zeleke AJ, Bezabih MK, Semaw M, Wubetie M, Abebe W, Tamene E, Tegegne Y. Therapeutic efficacy and safety of artemether-lumefantrine combination therapy for the treatment of uncomplicated Plasmodium falciparum malaria at Teda Health Centre, Northwest Ethiopia, 2022/23. Malar J 2024; 23:266. [PMID: 39215366 PMCID: PMC11363363 DOI: 10.1186/s12936-024-05082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 08/17/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND The emergence of Plasmodium falciparum drug resistance against artemisinin-based combination therapy has threatened malaria control efforts. Since malaria control and elimination plans are dependent on these drugs, they must remain efficacious. However, resistance to these drugs was detected in low-transmission settings and is predicted to emerge in high-transmission settings, including in unspecified areas of Ethiopia. Therefore, this study aimed to assess the therapeutic efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated P. falciparum malaria. METHODS A single-arm prospective observational study was conducted at Teda Health Centre, Northwest Ethiopia, by following the 2009 World Health Organization efficacy study guidelines from September 2022 to February 2023. Patients with uncomplicated falciparum malaria were conveniently selected and treated with a standard dose of artemether-lumefantrine, along with a single low dose of primaquine. Then clinical and parasitological responses and haemoglobin levels were assessed during the 28-day scheduled follow-up. Blood films were examined and asexual parasites were quantified; axillary temperature was measured; and drug adverse events were assessed throughout the follow-up. Finally, the drug efficacy (adequate clinical and parasitological response) was determined by Kaplan-Meier and per-protocol analyses. The data were analysed using the WHO Excel spreadsheet and SPSS version 25 software. RESULTS The success rates of PCR uncorrected and corrected Kaplan-Meier analysis on day 28 were 95.8% (95% CI 87.5-98.6) and 97.3% (95% CI 89.4-99.3), respectively. The per-protocol PCR uncorrected and corrected adequate clinical and parasitological responses were 95.5% (95% CI 87.5-99.1) and 97% (95% CI 89.5-99.6), respectively. On day-3, 97% of study participants were free of asexual parasitaemia, and all of them were fever-free on day-2. All of the gametocyte-positive patients at baseline were found to be negative for gametocytes on day-2. Moreover, the baseline mean hemoglobin of 13.10 g/dl increased slightly on day-14 to 13.27 g/dl but significantly on day-28 to 13.69 g/dl in a paired sample t test. All adverse events reported were mild. CONCLUSION Artemether-lumefantrine continued to be an efficacious and safe drug for the treatment of uncomplicated Plasmodium falciparum malaria at the Teda Health Centre. TRIAL REGISTRATION unique ID# PACTR202309773069812 at https://pactr.samrc.ac.za on September 1, 2023.
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Affiliation(s)
- Dagmawi Woldesenbet
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia.
| | - Meseret Birhanie
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aberham Abere
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ayalew Jejaw Zeleke
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Migbaru Keffale Bezabih
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Muluken Semaw
- Medical Laboratory Unit, Sanja General Hospital, Amhara National Regional State Health Bureau, Sanja, Ethiopia
| | - Menberu Wubetie
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Wagaw Abebe
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Elias Tamene
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Yalewayker Tegegne
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Angwe MK, Mwebaza N, Nsobya SL, Vudriko P, Dralabu S, Omali D, Tumwebaze MA, Ocan M. Day 3 parasitemia and Plasmodium falciparum Kelch 13 mutations among uncomplicated malaria patients treated with artemether-lumefantrine in Adjumani district, Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.26.24306433. [PMID: 38712186 PMCID: PMC11071562 DOI: 10.1101/2024.04.26.24306433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Artemisinin resistance threatens malaria control and elimination efforts globally. Recent studies have reported the emergence of Plasmodium falciparum parasites tolerant to artemisinin agents in sub-Saharan Africa, including Uganda. The current study assessed the day 3 parasite clearance and its correlation with P. falciparum K13 propeller gene (pfkelch13) mutations in P. falciparum parasites isolated from patients with uncomplicated malaria under artemether-lumefantrine (AL) treatment. This study enrolled 100 P. falciparum-positive patients to whom AL was prescribed between 09/September/2022 and 06/November/2022. Blood samples were collected in EDTA tubes before treatment initiation (day 0) and on day 3. Parasitemia was assessed by microscopy from blood smears and quantitative polymerase chain reaction (qPCR) from the DNA extracted. The day 0 parasite K13 gene was sequenced using Sanger sequencing. Sequence data were analysed using MEGA version 11 software. The data were analysed using STATA version 15, and the Mann‒Whitney U test was used to compare PCR parasite clearance on day 3 using the comparative CT value method and pfkelch13 mutations. The prevalence of day 3 parasitaemia was 24% (24/100) by microscopy and 63% (63/100) by qPCR from the AL-treated patients. P. falciparum K13-propeller gene polymorphism was detected in 18.8% (15/80) of the day 0 DNA samples. The K13 mutations found were C469Y, 12.5% (10/80); A675V, 2.5% (2/80); A569S, 1.25%, (1/80), A578S, 1.25%, (1/80) and; F491S, 1.25%, (1/80) a new allele not reported anywhere. The C469Y mutation, compared to the wild-type, was associated with delayed parasite clearance p=0.0278, Hodges-Lehmann estimation 3.2108 on the log scale, (95%CI 1.7076, 4.4730). There was a high prevalence of day 3 P. falciparum among malaria patients treated using artemether-lumefantrine. We conclude that the K13 mutation associated with artemisinin resistance by P. falciparum is present in Adjumani district, Uganda. This necessitates regular surveillance of the effectiveness and efficacy of artemether-lumefantrine in the country.
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Affiliation(s)
- Martin Kamilo Angwe
- Department of Pharmacology and Therapeutics, College of Health Science, Makerere University
- Research Center for Tropical Diseases and Vector Control, Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University
- Department of Biomolecular Resources and Biolab Sciences, School of Biosecurity, Biotechnical and Laboratory Science, College of Veterinary Medicine, Animal Resources and Biosecurity Makerere University
| | - Norah Mwebaza
- Department of Pharmacology and Therapeutics, College of Health Science, Makerere University
| | | | - Patrick Vudriko
- Research Center for Tropical Diseases and Vector Control, Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University
| | - Savior Dralabu
- Research Center for Tropical Diseases and Vector Control, Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University
| | - Denis Omali
- Department of Pharmacology and Therapeutics, College of Health Science, Makerere University
- Infectious Disease Institute, Makerere University
| | - Maria Agnes Tumwebaze
- Research Center for Tropical Diseases and Vector Control, Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University
| | - Moses Ocan
- Department of Pharmacology and Therapeutics, College of Health Science, Makerere University
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Fola AA, Feleke SM, Mohammed H, Brhane BG, Hennelly CM, Assefa A, Crudal RM, Reichert E, Juliano JJ, Cunningham J, Mamo H, Solomon H, Tasew G, Petros B, Parr JB, Bailey JA. Plasmodium falciparum resistant to artemisinin and diagnostics have emerged in Ethiopia. Nat Microbiol 2023; 8:1911-1919. [PMID: 37640962 PMCID: PMC10522486 DOI: 10.1038/s41564-023-01461-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/26/2023] [Indexed: 08/31/2023]
Abstract
Diagnosis and treatment of Plasmodium falciparum infections are required for effective malaria control and are pre-requisites for malaria elimination efforts; hence we need to monitor emergence, evolution and spread of drug- and diagnostics-resistant parasites. We deep sequenced key drug-resistance mutations and 1,832 SNPs in the parasite genomes of 609 malaria cases collected during a diagnostic-resistance surveillance study in Ethiopia. We found that 8.0% (95% CI 7.0-9.0) of malaria cases were caused by P. falciparum carrying the candidate artemisinin partial-resistance kelch13 (K13) 622I mutation, which was less common in diagnostic-resistant parasites mediated by histidine-rich proteins 2 and 3 (pfhrp2/3) deletions than in wild-type parasites (P = 0.03). Identity-by-descent analyses showed that K13 622I parasites were significantly more related to each other than to wild type (P < 0.001), consistent with recent expansion and spread of this mutation. Pfhrp2/3-deleted parasites were also highly related, with evidence of clonal transmissions at the district level. Of concern, 8.2% of K13 622I parasites also carried the pfhrp2/3 deletions. Close monitoring of the spread of combined drug- and diagnostic-resistant parasites is needed.
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Affiliation(s)
- Abebe A Fola
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | | | | | | | - Christopher M Hennelly
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Ashenafi Assefa
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca M Crudal
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Emily Reichert
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Jonathan J Juliano
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Jane Cunningham
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Hassen Mamo
- Department of Microbial, Cellular and Molecular Biology, College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Geremew Tasew
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Beyene Petros
- Department of Microbial, Cellular and Molecular Biology, College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jonathan B Parr
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Jeffrey A Bailey
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA.
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.
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Tadele G, Jawara A, Oboh M, Oriero E, Dugassa S, Amambua-Ngwa A, Golassa L. Clinical isolates of uncomplicated falciparum malaria from high and low malaria transmission areas show distinct pfcrt and pfmdr1 polymorphisms in western Ethiopia. Malar J 2023; 22:171. [PMID: 37270589 DOI: 10.1186/s12936-023-04602-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/20/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Pfcrt gene has been associated with chloroquine resistance and the pfmdr1 gene can alter malaria parasite susceptibility to lumefantrine, mefloquine, and chloroquine. In the absence of chloroquine (CQ) and extensive use of artemether-lumefantrine (AL) from 2004 to 2020 to treat uncomplicated falciparum malaria, pfcrt haplotype, and pfmdr1 single nucleotide polymorphisms (SNPs) were determined in two sites of West Ethiopia with a gradient of malaria transmission. METHODS 230 microscopically confirmed P. falciparum isolates were collected from Assosa (high transmission area) and Gida Ayana (low transmission area) sites, of which 225 of them tested positive by PCR. High-Resolution Melting Assay (HRM) was used to determine the prevalence of pfcrt haplotypes and pfmdr1 SNPs. Furthermore, the pfmdr1 gene copy number (CNV) was determined using real-time PCR. A P-value of less or equal to 0.05 was considered significant. RESULTS Of the 225 samples, 95.5%, 94.4%, 86.7%, 91.1%, and 94.2% were successfully genotyped with HRM for pfcrt haplotype, pfmdr1-86, pfmdr1-184, pfmdr1-1042 and pfmdr1-1246, respectively. The mutant pfcrt haplotypes were detected among 33.5% (52/155) and 80% (48/60) of isolates collected from the Assosa and Gida Ayana sites, respectively. Plasmodium falciparum with chloroquine-resistant haplotypes was more prevalent in the Gida Ayana area compared with the Assosa area (COR = 8.4, P = 0.00). Pfmdr1-N86Y wild type and 184F mutations were found in 79.8% (166/208) and 73.4% (146/199) samples, respectively. No single mutation was observed at the pfmdr1-1042 locus; however, 89.6% (190/212) of parasites in West Ethiopia carry the wild-type D1246Y variants. Eight pfmdr1 haplotypes at codons N86Y-Y184F-D1246Y were identified with the dominant NFD 61% (122/200). There was no difference in the distribution of pfmdr1 SNPs, haplotypes, and CNV between the two study sites (P > 0.05). CONCLUSION Plasmodium falciparum with the pfcrt wild-type haplotype was prevalent in high malaria transmission site than in low transmission area. The NFD haplotype was the predominant haplotype of the N86Y-Y184F-D1246Y. A continuous investigation is needed to closely monitor the changes in the pfmdr1 SNPs, which are associated with the selection of parasite populations by ACT.
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Affiliation(s)
- Geletta Tadele
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aminata Jawara
- Medical Research Council Unit the Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Mary Oboh
- Medical Research Council Unit the Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Eniyou Oriero
- Medical Research Council Unit the Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Sisay Dugassa
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfred Amambua-Ngwa
- Medical Research Council Unit the Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Lemu Golassa
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
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Funwei RI, Uyaiabasi GN, Hammed WA, Ojurongbe O, Walker O, Falade CO. High prevalence of persistent residual parasitemia on days 3 and 14 after artemether-lumefantrine or pyronaridine-artesunate treatment of uncomplicated Plasmodium falciparum malaria in Nigeria. Parasitol Res 2023; 122:519-526. [PMID: 36510009 DOI: 10.1007/s00436-022-07753-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Microscopic evaluation of parasite clearance is the gold standard in antimalarial drug efficacy trials. However, the presence of sub-microscopic residual parasitemia after artemisinin-based combination therapy (ACT) needs to be investigated. METHODS One hundred and twenty (AL: n = 60, PA: n = 60) days 3 and 14 dried blood spots, negative by microscopy were analysed for residual parasitemia using nested PCR. Isolates with residual parasitemia on days 3 and 14 were further genotyped with their corresponding day-0 isolates using merozoite surface proteins msp-1, msp-2, and glurp genes for allelic similarity. RESULTS Persistent PCR-determined sub-microscopic residual parasitemia at day 3 post ACT treatment was 83.3 (AL) and 88.3% (PA), respectively (ρ = 0.600), while 63.6 and 36.4% (ρ = 0.066) isolates were parasitemic at day 14 for AL and PA, respectively. Microscopy-confirmed gametocytemia persisted from days 0 to 7 and from days 0 to 21 for AL and PA. When the alleles of day 3 versus day 0 were compared according to base pair sizes, 59% of parasites shared identical alleles for glurp, 36% each for 3D7 and FC27, while K1 was 77%, RO33 64%, and MAD20 23%, respectively. Similarly, day 14 versus day 0 was 36% (glurp), 64% (3D7), and 32% (FC27), while 73% (K1), 77% (RO33), and 41% (MAD20), respectively. CONCLUSION The occurrence of residual parasitemia on days 3 and 14 following AL or PA treatment may be attributable to the presence of either viable asexual, gametocytes, or dead parasite DNAs, which requires further investigation.
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Affiliation(s)
- Roland I Funwei
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria. .,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria.
| | - Gabriel N Uyaiabasi
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria.,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Wasiu A Hammed
- Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Olusola Ojurongbe
- Department of Medical Microbiology, Ladoke Akintola University of Technology, Ogbomosho, Oyo State, Nigeria.,Center for Emerging and Re-Emerging Infectious Diseases (CERID), Ladoke Akintola University of Technology, Ogbomosho, Oyo State, Nigeria
| | - Oladapo Walker
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria.,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Catherine O Falade
- Department of Pharmacology and Therapeutics, University of Ibadan, Ibadan, Nigeria.,Institute for Advanced Medical Research and Training (IAMRAT), University of Ibadan, Ibadan, Nigeria
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