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Micchelli CE, Percopo C, Traver M, Brzostowski J, Amin SN, Prigge ST, Sá JM, Wellems TE. Progressive heterogeneity of enlarged and irregularly shaped apicoplasts in P. falciparum persister blood stages after drug treatment. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.03.574077. [PMID: 38410435 PMCID: PMC10896342 DOI: 10.1101/2024.01.03.574077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Morphological modifications and shifts in organelle relationships are hallmarks of dormancy in eukaryotic cells. Communications between altered mitochondria and nuclei are associated with metabolic quiescence of cancer cells that can survive chemotherapy. In plants, changes in the pathways between nuclei, mitochondria, and chloroplasts are associated with cold stress and bud dormancy. Plasmodium falciparum parasites, the deadliest agent of malaria in humans, contain a chloroplast-like organelle (apicoplast) derived from an ancient photosynthetic symbiont. Antimalarial treatments can fail because a small fraction of the blood stage parasites enter dormancy and recrudesce after drug exposure. Altered mitochondrial-nuclear interactions in these persisters have been described for P. falciparum, but interactions of the apicoplast remained to be characterized. In the present study, we examined the apicoplasts of dormant persisters obtained after exposure to dihydroartemisinin (a first-line antimalarial drug) followed by sorbitol treatment, or after exposure to sorbitol treatment alone. As previously observed, the mitochondrion of persisters was consistently enlarged and in close association with the nucleus. In contrast, the apicoplast varied from compact and oblate, like those of active ring stage parasites, to enlarged and irregularly shaped. Enlarged apicoplasts became more prevalent later in dormancy, but regular size apicoplasts subsequently predominated when actively replicating parasites recrudesced. All three organelles, nucleus, mitochondrion, and apicoplast, became closer during dormancy. Understanding their relationships in erythrocytic-stage persisters may lead to new strategies to prevent recrudescences and protect the future of malaria chemotherapy.
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Affiliation(s)
- Chiara E. Micchelli
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Caroline Percopo
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Traver
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph Brzostowski
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Shuchi N. Amin
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sean T. Prigge
- Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland, USA
| | - Juliana M. Sá
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas E. Wellems
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Chaorattanakawee S, Kosaisavee V, Bunsermyos W, Aonsri C, Imaram W, Suwannasin K, Kunasol C, Thamnurak C, Boonyalai N, Saunders D, Dondorp AM, Mungthin M, Imwong M. In vitro activity of rhinacanthin analogues against drug resistant Plasmodium falciparum isolates from Northeast Thailand. Malar J 2023; 22:105. [PMID: 36959593 PMCID: PMC10035203 DOI: 10.1186/s12936-023-04532-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/13/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND New anti-malarial drugs are needed urgently to address the increasing challenges of drug-resistant falciparum malaria. Two rhinacanthin analogues containing a naphthoquinone moiety resembling atovaquone showed promising in-vitro activity against a P. falciparum laboratory reference strain (K1). The anti-malarial activity of these 2 compounds was further evaluated for P. falciparum field isolates from an area of multi-drug resistance in Northeast Thailand. METHODS Using a pLDH enzyme-linked immunosorbent assay, four P. falciparum isolates from Northeast Thailand in 2018 were tested for in vitro sensitivity to the two synthetic rhinacanthin analogues 1 and 2 as well as established anti-malarials. Mutations in the P. falciparum cytochrome b gene, a marker for atovaquone (ATQ) resistance, were genotyped in all four field isolates as well as 100 other clinical isolates from the same area using PCR-artificial Restriction Fragment Length Polymorphisms. Pfkelch13 mutations, a marker for artemisinin (ART) resistance, were also examined in all isolates. RESULTS The 50% inhibitory concentrations (IC50) of P. falciparum field isolates for rhinacanthin analogue 1 was 321.9-791.1 nM (median = 403.1 nM). Parasites were more sensitive to analogue 2: IC50 48.6-63.3 nM (median = 52.2 nM). Similar results were obtained against P. falciparum reference laboratory strains 3D7 and W2. The ART-resistant IPC-5202 laboratory strain was more sensitive to these compounds with a median IC50 45.9 and 3.3 nM for rhinacanthin analogues 1 and 2, respectively. The ATQ-resistant C2B laboratory strain showed high-grade resistance towards both compounds (IC50 > 15,000 nM), and there was a strong positive correlation between the IC50 values for these compounds and ATQ (r = 0.83-0.97, P < 0.001). There were no P. falciparum cytochrome b mutations observed in the field isolates, indicating that P. falciparum isolates from this area remained ATQ-sensitive. Pfkelch13 mutations and the ring-stage survival assay confirmed that most isolates were resistant to ART. CONCLUSIONS Two rhinacanthin analogues showed parasiticidal activity against multi-drug resistant P. falciparum isolates, although less potent than ATQ. Rhinacanthin analogue 2 was more potent than analogue 1, and can be a lead compound for further optimization as an anti-malarial in areas with multidrug resistance.
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Affiliation(s)
- Suwanna Chaorattanakawee
- Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Varakorn Kosaisavee
- Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Watanyu Bunsermyos
- Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Chaiyawat Aonsri
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Mahidol University, Bangkok, 10400, Thailand
| | - Witcha Imaram
- Department of Chemistry and Center of Excellence for Innovation in Chemistry, Faculty of Science, Kasetsart University, Bangkok, Thailand
| | - Kanokon Suwannasin
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chanon Kunasol
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chatchadaporn Thamnurak
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Science (AFRIMS), Bangkok, Thailand
| | - Nonlawat Boonyalai
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Science (AFRIMS), Bangkok, Thailand
| | - David Saunders
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mathirut Mungthin
- Department of Parasitology, Phramongkutklao College of Medicine, 317 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Lek D, Rachmat A, Harrison D, Chin G, Chaoratanakawee S, Saunders D, Menard D, Rogers WO. Efficacy of three anti-malarial regimens for uncomplicated Plasmodium falciparum malaria in Cambodia, 2009-2011: a randomized controlled trial and brief review. Malar J 2022; 21:259. [PMID: 36071520 PMCID: PMC9450427 DOI: 10.1186/s12936-022-04279-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 08/28/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anti-malarial resistance remains an important public health challenge in Cambodia. The effectiveness of three therapies for uncomplicated falciparum malaria was evaluated in Oddar Meanchey province in Northern Cambodia from 2009 to 2011. METHODS In this randomized, open-label, parallel group-controlled trial, 211 subjects at least 5 years old with uncomplicated falciparum malaria were treated with 3 days of directly observed therapy: 63 received artesunate-mefloquine (AS/MQ), 77 received dihydroartemisinin-piperaquine (DHA/PPQ), and 71 received atovaquone-proguanil (ATQ/PG). The subjects were followed for 42 days or until recurrent parasitaemia. Genotyping of msp1, msp2, and glurp among individual parasite isolates distinguished recrudescence from reinfection. Pfmdr1 copy number was measured by real-time PCR and half-maximal parasite inhibitory concentrations (IC50) were measured in vitro by 48-h isotopic hypoxanthine incorporation assay. RESULTS The per-protocol PCR-adjusted efficacy (95% confidence interval) at 42 days was 80.6% (70.8-90.5%) for AS/MQ, 97.2% (93.3-100%) for DHA/PPQ, and 92.9% (86.1-99.6%) for ATQ/PG. On day 3, 57.9% remained parasitaemic in the AS/MQ and DHA/PPQ arms. At baseline, 46.9% had microscopic Plasmodium falciparum gametocytaemia. Both recurrences in the DHA/PPQ arm lost Pfmdr1 copy number amplification at recrudescence. All four recurrences in the ATQ/PG arm were wild-type for cytochrome bc1. One subject withdrew from the ATQ/PG arm due to drug allergy. CONCLUSIONS This study was conducted at the epicentre of substantial multi-drug resistance that emerged soon thereafter. Occurring early in the national transition from AS/MQ to DHA/PPQ, both DHA/PPQ and ATQ/PG had acceptable efficacy against uncomplicated falciparum malaria. However, efficacy of AS/MQ was only 80% with apparent mefloquine resistance based on elevated Pfmdr1 copy number and IC50. By 2009, there was already significant evidence of artemisinin resistance not previously reported at the Northern Cambodia-Thai border. This study suggests the basis for early development of significant DHA/PPQ failures within 3 years of introduction. Artemisinin resistance likely occurred on the Northern border concurrently with that reported along the Western border in Pailin. Trial registration This legacy trial was conducted prior to International Committee of Medical Journal Editors' requirements for preregistration on ClinicalTrials.gov. The full protocol has been provided.
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Affiliation(s)
- Dysoley Lek
- National Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
| | - Agus Rachmat
- U.S. Naval Medical Research Unit 2, Phnom Penh, Cambodia
| | | | - Geoffrey Chin
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - David Saunders
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Masserey T, Lee T, Golumbeanu M, Shattock AJ, Kelly SL, Hastings IM, Penny MA. The influence of biological, epidemiological, and treatment factors on the establishment and spread of drug-resistant Plasmodium falciparum. eLife 2022; 11:77634. [PMID: 35796430 PMCID: PMC9262398 DOI: 10.7554/elife.77634] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
The effectiveness of artemisinin-based combination therapies (ACTs) to treat Plasmodium falciparum malaria is threatened by resistance. The complex interplay between sources of selective pressure-treatment properties, biological factors, transmission intensity, and access to treatment-obscures understanding how, when, and why resistance establishes and spreads across different locations. We developed a disease modelling approach with emulator-based global sensitivity analysis to systematically quantify which of these factors drive establishment and spread of drug resistance. Drug resistance was more likely to evolve in low transmission settings due to the lower levels of (i) immunity and (ii) within-host competition between genotypes. Spread of parasites resistant to artemisinin partner drugs depended on the period of low drug concentration (known as the selection window). Spread of partial artemisinin resistance was slowed with prolonged parasite exposure to artemisinin derivatives and accelerated when the parasite was also resistant to the partner drug. Thus, to slow the spread of partial artemisinin resistance, molecular surveillance should be supported to detect resistance to partner drugs and to change ACTs accordingly. Furthermore, implementing more sustainable artemisinin-based therapies will require extending parasite exposure to artemisinin derivatives, and mitigating the selection windows of partner drugs, which could be achieved by including an additional long-acting drug.
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Affiliation(s)
- Thiery Masserey
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Tamsin Lee
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Monica Golumbeanu
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Andrew J Shattock
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Sherrie L Kelly
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Ian M Hastings
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Melissa A Penny
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
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Boonyalai N, Kirativanich K, Thamnurak C, Praditpol C, Vesely BA, Wojnarski M, Griesenbeck JS, Waters NC. A single point mutation in the Plasmodium falciparum 3'-5' exonuclease does not alter piperaquine susceptibility. Malar J 2022; 21:130. [PMID: 35459163 PMCID: PMC9034581 DOI: 10.1186/s12936-022-04148-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background The rise in Plasmodium falciparum resistance to dihydroartemisinin–piperaquine (DHA–PPQ) treatment has been documented in the Greater Mekong Subregion with associations with mutations in the P. falciparum chloroquine resistance transporter (pfcrt) and plasmepsin 2 (pfpm2) genes. However, it is unclear whether other genes also play a role with PPQ resistance, such as the E415G mutation in the exonuclease (pfexo) gene. The aim of this study was to investigate the role of this mutation in PPQ resistance by generating transgenic parasites expressing the pfexo-E415G mutant allele. Methods Transgenic parasite clones carrying the E415G mutation in PfEXO of the B5 isolate were derived by CRISPR-Cas9 gene editing and verified using PCR and gene sequencing. Polymorphisms of pfkelch-13, pfcrt, and pfexo were examined by PCR while the copy number variations of pfpm2 were examined by both relative quantitative real-time PCR and the duplication breakpoint assay. Drug sensitivity against a panel of antimalarials, the ring-stage survival assay (RSA), the PPQ survival assay (PSA), and bimodal dose-response curves were used to evaluate antimalarial susceptibility. Results The transgenic line, B5-rexo-E415G-B8, was successfully generated. The PPQ-IC90, %PPQ survival, and the bimodal dose-response clearly showed that E415G mutation in PfEXO of B5 isolate remained fully susceptible to PPQ. Furthermore, growth assays demonstrated that the engineered parasites grew slightly faster than the unmodified parental isolates whereas P. falciparum isolates harbouring pfkelch-13, pfcrt, and pfexo mutations with multiple copies of pfpm2 grew much more slowly. Conclusions Insertion of the E415G mutation in PfEXO did not lead to increased PPQ-IC90 and %PPQ survival, suggesting that this mutation alone may not be associated with PPQ resistance, but could still be an important marker if used in conjunction with other markers for monitoring PPQ-resistant parasites. The results also highlight the importance of monitoring and evaluating suspected genetic mutations with regard to parasite fitness and resistance. Supplementary information The online version contains supplementary material available at 10.1186/s12936-022-04148-z.
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Affiliation(s)
- Nonlawat Boonyalai
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.
| | - Kirakarn Kirativanich
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chatchadaporn Thamnurak
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chantida Praditpol
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Brian A Vesely
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mariusz Wojnarski
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - John S Griesenbeck
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Norman C Waters
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
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Marfurt J, Wirjanata G, Prayoga P, Chalfein F, Leonardo L, Sebayang BF, Apriyanti D, Sihombing MAEM, Trianty L, Suwanarusk R, Brockman A, Piera KA, Luo I, Rumaseb A, MacHunter B, Auburn S, Anstey NM, Kenangalem E, Noviyanti R, Russell B, Poespoprodjo JR, Price RN. Longitudinal ex vivo and molecular trends of chloroquine and piperaquine activity against Plasmodium falciparum and P. vivax before and after introduction of artemisinin-based combination therapy in Papua, Indonesia. Int J Parasitol Drugs Drug Resist 2021; 17:46-56. [PMID: 34193398 PMCID: PMC8358472 DOI: 10.1016/j.ijpddr.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 01/13/2023]
Abstract
Drug resistant Plasmodium parasites are a major threat to malaria control and elimination. After reports of high levels of multidrug resistant P. falciparum and P. vivax in Indonesia, in 2005, the national first-line treatment policy for uncomplicated malaria was changed in March 2006, to dihydroartemisinin-piperaquine against all species. This study assessed the temporal trends in ex vivo drug susceptibility to chloroquine (CQ) and piperaquine (PIP) for both P. falciparum and P. vivax clinical isolates collected between 2004 and 2018, by using schizont maturation assays, and genotyped a subset of isolates for known and putative molecular markers of CQ and PIP resistance by using Sanger and next generation whole genome sequencing. The median CQ IC50 values varied significantly between years in both Plasmodium species, but there was no significant trend over time. In contrast, there was a significant trend for increasing PIP IC50s in both Plasmodium species from 2010 onwards. Whereas the South American CQ resistant 7G8 pfcrt SVMNT isoform has been fixed since 2005 in the study area, the pfmdr1 86Y allele frequencies decreased and became fixed at the wild-type allele in 2015. In P. vivax isolates, putative markers of CQ resistance (no pvcrt-o AAG (K10) insertion and pvmdr1 Y967F and F1076L) were fixed at the mutant alleles since 2005. None of the putative PIP resistance markers were detected in P. falciparum. The ex vivo drug susceptibility and molecular analysis of CQ and PIP efficacy for P. falciparum and P. vivax after 12 years of intense drug pressure with DHP suggests that whilst the degree of CQ resistance appears to have been sustained, there has been a slight decline in PIP susceptibility, although this does not appear to have reached clinically significant levels. The observed decreasing trend in ex vivo PIP susceptibility highlights the importance of ongoing surveillance.
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Affiliation(s)
- Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia.
| | - Grennady Wirjanata
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Pak Prayoga
- Papuan Health and Community Development Foundation (PHCDF), Jl. Caritas No. 1, 99961, Timika, Papua, Indonesia
| | - Ferryanto Chalfein
- Papuan Health and Community Development Foundation (PHCDF), Jl. Caritas No. 1, 99961, Timika, Papua, Indonesia
| | - Leo Leonardo
- Papuan Health and Community Development Foundation (PHCDF), Jl. Caritas No. 1, 99961, Timika, Papua, Indonesia
| | - Boni F Sebayang
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia
| | - Dwi Apriyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia
| | - Maic A E M Sihombing
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia
| | - Rossarin Suwanarusk
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Alan Brockman
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Kim A Piera
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Irene Luo
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Angela Rumaseb
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Barbara MacHunter
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Sarah Auburn
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Enny Kenangalem
- Papuan Health and Community Development Foundation (PHCDF), Jl. Caritas No. 1, 99961, Timika, Papua, Indonesia; District Health Authority, Timika, Papua, Indonesia
| | - Rintis Noviyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia
| | - Bruce Russell
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia
| | - Jeanne R Poespoprodjo
- Papuan Health and Community Development Foundation (PHCDF), Jl. Caritas No. 1, 99961, Timika, Papua, Indonesia; Paediatric Research Office, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Darwin, Australia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
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Siddiqui FA, Liang X, Cui L. Plasmodium falciparum resistance to ACTs: Emergence, mechanisms, and outlook. Int J Parasitol Drugs Drug Resist 2021; 16:102-118. [PMID: 34090067 PMCID: PMC8188179 DOI: 10.1016/j.ijpddr.2021.05.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/06/2021] [Accepted: 05/21/2021] [Indexed: 01/18/2023]
Abstract
Emergence and spread of resistance in Plasmodium falciparum to the frontline treatment artemisinin-based combination therapies (ACTs) in the epicenter of multidrug resistance of Southeast Asia threaten global malaria control and elimination. Artemisinin (ART) resistance (or tolerance) is defined clinically as delayed parasite clearance after treatment with an ART drug. The resistance phenotype is restricted to the early ring stage and can be measured in vitro using a ring-stage survival assay. ART resistance is associated with mutations in the propeller domain of the Kelch family protein K13. As a pro-drug, ART is activated primarily by heme, which is mainly derived from hemoglobin digestion in the food vacuole. Activated ARTs can react promiscuously with a wide range of cellular targets, disrupting cellular protein homeostasis. Consistent with this mode of action for ARTs, the molecular mechanisms of K13-mediated ART resistance involve reduced hemoglobin uptake/digestion and increased cellular stress response. Mutations in other genes such as AP-2μ (adaptor protein-2 μ subunit), UBP-1 (ubiquitin-binding protein-1), and Falcipain 2a that interfere with hemoglobin uptake and digestion also increase resistance to ARTs. ART resistance has facilitated the development of resistance to the partner drugs, resulting in rapidly declining ACT efficacies. The molecular markers for resistance to the partner drugs are mostly associated with point mutations in the two food vacuole membrane transporters PfCRT and PfMDR1, and amplification of pfmdr1 and the two aspartic protease genes plasmepsin 2 and 3. It has been observed that mutations in these genes can have opposing effects on sensitivities to different partner drugs, which serve as the principle for designing triple ACTs and drug rotation. Although clinical ACT resistance is restricted to Southeast Asia, surveillance for drug resistance using in vivo clinical efficacy, in vitro assays, and molecular approaches is required to prevent or slow down the spread of resistant parasites.
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Affiliation(s)
- Faiza Amber Siddiqui
- Department of Internal Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Xiaoying Liang
- Department of Internal Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Liwang Cui
- Department of Internal Medicine, University of South Florida, Tampa, FL, 33612, USA.
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8
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Wicht KJ, Mok S, Fidock DA. Molecular Mechanisms of Drug Resistance in Plasmodium falciparum Malaria. Annu Rev Microbiol 2021; 74:431-454. [PMID: 32905757 DOI: 10.1146/annurev-micro-020518-115546] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Understanding and controlling the spread of antimalarial resistance, particularly to artemisinin and its partner drugs, is a top priority. Plasmodium falciparum parasites resistant to chloroquine, amodiaquine, or piperaquine harbor mutations in the P. falciparum chloroquine resistance transporter (PfCRT), a transporter resident on the digestive vacuole membrane that in its variant forms can transport these weak-base 4-aminoquinoline drugs out of this acidic organelle, thus preventing these drugs from binding heme and inhibiting its detoxification. The structure of PfCRT, solved by cryogenic electron microscopy, shows mutations surrounding an electronegative central drug-binding cavity where they presumably interact with drugs and natural substrates to control transport. P. falciparum susceptibility to heme-binding antimalarials is also modulated by overexpression or mutations in the digestive vacuole membrane-bound ABC transporter PfMDR1 (P. falciparum multidrug resistance 1 transporter). Artemisinin resistance is primarily mediated by mutations in P. falciparum Kelch13 protein (K13), a protein involved in multiple intracellular processes including endocytosis of hemoglobin, which is required for parasite growth and artemisinin activation. Combating drug-resistant malaria urgently requires the development of new antimalarial drugs with novel modes of action.
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Affiliation(s)
- Kathryn J Wicht
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York 10032, USA; , ,
| | - Sachel Mok
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York 10032, USA; , ,
| | - David A Fidock
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York 10032, USA; , , .,Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York 10032, USA
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Boonyalai N, Thamnurak C, Sai-Ngam P, Ta-Aksorn W, Arsanok M, Uthaimongkol N, Sundrakes S, Chattrakarn S, Chaisatit C, Praditpol C, Fagnark W, Kirativanich K, Chaorattanakawee S, Vanachayangkul P, Lertsethtakarn P, Gosi P, Utainnam D, Rodkvamtook W, Kuntawunginn W, Vesely BA, Spring MD, Fukuda MM, Lanteri C, Walsh D, Saunders DL, Smith PL, Wojnarski M, Sirisopana N, Waters NC, Jongsakul K, Gaywee J. Plasmodium falciparum phenotypic and genotypic resistance profile during the emergence of Piperaquine resistance in Northeastern Thailand. Sci Rep 2021; 11:13419. [PMID: 34183715 PMCID: PMC8238947 DOI: 10.1038/s41598-021-92735-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/15/2021] [Indexed: 11/09/2022] Open
Abstract
Malaria remains a public health problem in Thailand, especially along its borders where highly mobile populations can contribute to persistent transmission. This study aimed to determine resistant genotypes and phenotypes of 112 Plasmodium falciparum isolates from patients along the Thai-Cambodia border during 2013-2015. The majority of parasites harbored a pfmdr1-Y184F mutation. A single pfmdr1 copy number had CVIET haplotype of amino acids 72-76 of pfcrt and no pfcytb mutations. All isolates had a single pfk13 point mutation (R539T, R539I, or C580Y), and increased % survival in the ring-stage survival assay (except for R539I). Multiple copies of pfpm2 and pfcrt-F145I were detected in 2014 (12.8%) and increased to 30.4% in 2015. Parasites containing either multiple pfpm2 copies with and without pfcrt-F145I or a single pfpm2 copy with pfcrt-F145I exhibited elevated IC90 values of piperaquine. Collectively, the emergence of these resistance patterns in Thailand near Cambodia border mirrored the reports of dihydroartemisinin-piperaquine treatment failures in the adjacent province of Cambodia, Oddar Meanchey, suggesting a migration of parasites across the border. As malaria elimination efforts ramp up in Southeast Asia, host nations militaries and other groups in border regions need to coordinate the proposed interventions.
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Affiliation(s)
- Nonlawat Boonyalai
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.
| | - Chatchadaporn Thamnurak
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Piyaporn Sai-Ngam
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Winita Ta-Aksorn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Montri Arsanok
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Nichapat Uthaimongkol
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Siratchana Sundrakes
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Sorayut Chattrakarn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chaiyaporn Chaisatit
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chantida Praditpol
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Watcharintorn Fagnark
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Kirakarn Kirativanich
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Suwanna Chaorattanakawee
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.,Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Pattaraporn Vanachayangkul
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Paphavee Lertsethtakarn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Panita Gosi
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Darunee Utainnam
- Royal Thai Army Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Wuttikon Rodkvamtook
- Royal Thai Army Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Worachet Kuntawunginn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Brian A Vesely
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Michele D Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mark M Fukuda
- Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Charlotte Lanteri
- Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - Douglas Walsh
- Department of Dermatology, Syracuse VA medical center, Syracuse, USA
| | - David L Saunders
- U.S. Army Research Institute of Infectious Diseases, Frederick, MD, USA
| | - Philip L Smith
- Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - Mariusz Wojnarski
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Narongrid Sirisopana
- Royal Thai Army Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Norman C Waters
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Krisada Jongsakul
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Jariyanart Gaywee
- Royal Thai Army Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
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K13-Mediated Reduced Susceptibility to Artemisinin in Plasmodium falciparum Is Overlaid on a Trait of Enhanced DNA Damage Repair. Cell Rep 2021; 32:107996. [PMID: 32755588 PMCID: PMC7408483 DOI: 10.1016/j.celrep.2020.107996] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/21/2020] [Accepted: 07/14/2020] [Indexed: 11/23/2022] Open
Abstract
Southeast Asia has been the hotbed for the development of drug-resistant malaria parasites, including those with resistance to artemisinin combination therapy. While mutations in the kelch propeller domain (K13 mutations) are associated with artemisinin resistance, a range of evidence suggests that other factors are critical for the establishment and subsequent transmission of resistance in the field. Here, we perform a quantitative analysis of DNA damage and repair in the malaria parasite Plasmodium falciparum and find a strong link between enhanced DNA damage repair and artemisinin resistance. This experimental observation is further supported when variations in seven known DNA repair genes are found in resistant parasites, with six of these mutations being associated with K13 mutations. Our data provide important insights on confounding factors that are important for the establishment and spread of artemisinin resistance and may explain why resistance has not yet arisen in Africa. High-throughput MalariaCometChip to measure DNA damage level in P. falciparum Subpopulation of Cambodian isolates possess enhanced DNA damage repair Important link between enhanced DNA damage repair and artemisinin resistance
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11
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In Vitro Susceptibility of Plasmodium falciparum Isolates from the China-Myanmar Border Area to Piperaquine and Association with Candidate Markers. Antimicrob Agents Chemother 2021; 65:AAC.02305-20. [PMID: 33685900 PMCID: PMC8092910 DOI: 10.1128/aac.02305-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Plasmodium falciparum from the Greater Mekong subregion has evolved resistance to the artemisinin-based combination therapy dihydroartemisinin and the partner drug piperaquine. To monitor the potential westward spread or independent evolution of piperaquine resistance, we evaluated the in vitro susceptibility of 120 P. falciparum isolates collected at the China-Myanmar border during 2007-2016. The parasite isolates displayed a relatively wide range of piperaquine susceptibility estimates. While 56.7% of the parasites showed bimodal drug response curves, all but five generated area-under-the-curve (AUC) estimates consistent with a susceptible phenotype. Using the piperaquine survival assay (PSA), 5.6% parasites showed reduced susceptibility. Of note, parasites from 2014-2016 showed the highest AUC value and the highest proportion with a bimodal curve, suggesting falling effectiveness in these later years. Unsupervised K-mean analysis of the combined data assigned parasites into three clusters and identified significant correlations between IC50, IC90, and AUC values. No parasites carried the E415G mutation in a putative exo-nuclease, new mutations in PfCRT, or amplification of the plasmepsin 2/3 genes, suggesting mechanisms of reduced piperaquine susceptibility that differ from those described in other countries of the region. The association of increased AUC, IC50, and IC90 values with major PfK13 mutations (F446I and G533S) suggests that piperaquine resistance may evolve in these PfK13 genetic backgrounds. Additionally, the Pfmdr1 F1226Y mutation was associated with significantly higher PSA values. Further elucidation of piperaquine resistance mechanisms and continuous surveillance are warranted.
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12
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Improved Protocol for Continuous Culture of Plasmodium falciparum Reference Strains. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2021. [DOI: 10.22207/jpam.15.1.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Parasitic biobank of Plasmodium falciparum is almost germinal in Côte d’Ivoire. However, several high-level research topics on this parasite involve the taking into account of nature isolates but also chemo-sensitive or resistant reference strains for a better validation of results. In addition, acquisition of these reference strains is still arduous for laboratories in developing countries due to complexity of administrative procedures. For those reasons, this study aimed in to combine several procedures into a consolidated one in order to enhance the multiplication of P. falciparum reference strains. Continuous culture of plasmodial strains was based on the Trager and Jensen procedures. The CELL culture protocols used are those of the Swiss TPH described by Sergio Wittlin; the “Growing Plasmodium falciparum cultures at high parasitemia” and the “Stockholm sorbitol method” of Methods in Malaria Research-6th edition 2013; and the INV-01 and INV-02 procedures of the Worldwide Antimalarial Resistance Network (WWARN). Reference Plasmodium falciparum strains NF54 sensitive to chloroquine (CQs) and K1 resistant to chloroquine (CQr) were received from the Swiss Tropical Institute and Public Health (Swiss TPH). The CQs NF54 strain reacted more quickly to the protocol unlike the CQr K1 strain. Parasitic densities (DP) obtained with NF54 strain were ranged from 0.4% at day zero (D0) to 11.4% at day eight (D8). Strain K1 finally adapted successfully after one month of follow-up. Related DPs ranged from less than 0.1% to more than 20% in just three growth cycles after adaptation. A joint protocol (from this work) called “CRLP-SwissTPH-Pasteur_001” is available and allows to efficiently multiply reference strains NF54 and K1. It is planned to spread out the tests to other plasmodial strains as well as to wild isolates in order to standardize this procedure.
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13
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Shrestha B, Shah Z, Morgan AP, Saingam P, Chaisatit C, Chaorattanakawee S, Praditpol C, Boonyalai N, Lertsethtakarn P, Wojnarski M, Deutsch-Feldman M, Adams M, Sea D, Chann S, Tyner SD, Lanteri CA, Spring MD, Saunders DL, Smith PL, Lon C, Gosi P, Sok S, Satharath P, Rekol H, Lek D, Vesely BA, Lin JT, Waters NC, Takala-Harrison S. Distribution and temporal dynamics of P. falciparum chloroquine resistance transporter mutations associated with piperaquine resistance in Northern Cambodia. J Infect Dis 2021; 224:1077-1085. [PMID: 33528566 DOI: 10.1093/infdis/jiab055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/26/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Newly emerged mutations within the Plasmodium falciparum chloroquine resistance transporter (PfCRT) can confer piperaquine resistance in the absence of amplified plasmepsin II (pfpm2). In this study, we estimated the prevalence of co-circulating piperaquine resistance mutations in P. falciparum isolates collected in northern Cambodia from 2009-2017. METHODS The sequence of pfcrt was determined for 410 P. falciparum isolates using PacBio amplicon sequencing or whole genome sequencing. Quantitative PCR was used to estimate pfpm2 and pfmdr1 copy number. RESULTS Newly emerged PfCRT mutations increased in prevalence after the change to dihydroartemisinin-piperaquine in 2010, with >98% of parasites harboring these mutations by 2017. After 2014, the prevalence of PfCRT F145I declined, being out-competed by parasites with less resistant, but more fit PfCRT alleles. After the change to artesunate-mefloquine, the prevalence of parasites with amplified pfpm2 decreased, with nearly half of piperaquine-resistant PfCRT mutants having single copy pfpm2. CONCLUSIONS The large proportion of PfCRT mutants that lack pfpm2 amplification emphasizes the importance of including PfCRT mutations as part of molecular surveillance for piperaquine resistance in this region. Likewise, it is critical to monitor for amplified pfmdr1 in these PfCRT mutants, as increased mefloquine pressure could lead to mutants resistant to both drugs.
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Affiliation(s)
- Biraj Shrestha
- Malaria Research Program, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zalak Shah
- Malaria Research Program, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew P Morgan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Piyaporn Saingam
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Suwanna Chaorattanakawee
- Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | | | | | | | - Mariusz Wojnarski
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Matthew Adams
- Malaria Research Program, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Darapiseth Sea
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Soklyda Chann
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Stuart D Tyner
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Michele D Spring
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - David L Saunders
- US Army Research Institute of Infectious Diseases, Ft. Detrick, MD, USA
| | - Philip L Smith
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Panita Gosi
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Somethy Sok
- Royal Cambodian Armed Forces, Phnom Penh, Cambodia
| | | | - Huy Rekol
- National Center for Parasitology Entomology and Malaria Control, Village Trapangsvay, Sanakat Phnom Penh, Cambodia
| | - Dysoley Lek
- National Center for Parasitology Entomology and Malaria Control, Village Trapangsvay, Sanakat Phnom Penh, Cambodia
| | - Brian A Vesely
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Jessica T Lin
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Norman C Waters
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Shannon Takala-Harrison
- Malaria Research Program, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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14
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Fukuda N, Tachibana SI, Ikeda M, Sakurai-Yatsushiro M, Balikagala B, Katuro OT, Yamauchi M, Emoto S, Hashimoto M, Yatsushiro S, Sekihara M, Mori T, Hirai M, Opio W, Obwoya PS, Auma MA, Anywar DA, Kataoka M, Palacpac NMQ, Odongo-Aginya EI, Kimura E, Ogwang M, Horii T, Mita T. Ex vivo susceptibility of Plasmodium falciparum to antimalarial drugs in Northern Uganda. Parasitol Int 2020; 81:102277. [PMID: 33370608 DOI: 10.1016/j.parint.2020.102277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/10/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
In Uganda, artemether-lumefantrine was introduced as an artemisinin-based combination therapy (ACT) for malaria in 2006. We have previously reported a moderate decrease in ex vivo efficacy of lumefantrine in Northern Uganda, where we also detected ex vivo artemisinin-resistant Plasmodium falciparum. Therefore, it is necessary to search for candidate partner alternatives for ACT. Here, we investigated ex vivo susceptibility to four ACT partner drugs as well as quinine and chloroquine, in 321 cases between 2013 and 2018. Drug-resistant mutations in pfcrt and pfmdr1 were also determined. Ex vivo susceptibility to amodiaquine, quinine, and chloroquine was well preserved, whereas resistance to mefloquine was found in 45.8%. There were few cases of multi-drug resistance. Reduced sensitivity to mefloquine and lumefantrine was significantly associated with the pfcrt K76 wild-type allele, in contrast to the association between chloroquine resistance and the K76T allele. Pfmdr1 duplication was not detected in any of the cases. Amodiaquine, a widely used partner drug for ACT in African countries, may be the first promising alternative in case lumefantrine resistance emerges. Therapeutic use of mefloquine may not be recommended in this area. This study also emphasizes the need for sustained monitoring of antimalarial susceptibility in Northern Uganda to develop proper treatment strategies.
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Affiliation(s)
- Naoyuki Fukuda
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Shin-Ichiro Tachibana
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Mie Ikeda
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Miki Sakurai-Yatsushiro
- Department of International Affairs and Tropical Medicine, School of Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Betty Balikagala
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Osbert T Katuro
- Mildmay Uganda, Nazibwa Hill, Lweza, P.O. Box 24985, Kampala, Uganda
| | - Masato Yamauchi
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Sakurako Emoto
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Muneaki Hashimoto
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 2217-14, Hayashi-cho, Takamatsu, Kagawa, 761-0301, Japan
| | - Shouki Yatsushiro
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 2217-14, Hayashi-cho, Takamatsu, Kagawa, 761-0301, Japan
| | - Makoto Sekihara
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Toshiyuki Mori
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Makoto Hirai
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Walter Opio
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Paul S Obwoya
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Mary A Auma
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Denis A Anywar
- Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda
| | - Masatoshi Kataoka
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 2217-14, Hayashi-cho, Takamatsu, Kagawa, 761-0301, Japan
| | - Nirianne M Q Palacpac
- Department of Malaria Vaccine Development, Research Institute for Microbial Diseases, Osaka University, 3-1 Yamadaoka, Suita, Osaka 565-0871, Japan
| | | | - Eisaku Kimura
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, Nagasaki 852-8523, Japan
| | - Martin Ogwang
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Toshihiro Horii
- Department of Malaria Vaccine Development, Research Institute for Microbial Diseases, Osaka University, 3-1 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Toshihiro Mita
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
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15
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Boonyalai N, Vesely BA, Thamnurak C, Praditpol C, Fagnark W, Kirativanich K, Saingam P, Chaisatit C, Lertsethtakarn P, Gosi P, Kuntawunginn W, Vanachayangkul P, Spring MD, Fukuda MM, Lon C, Smith PL, Waters NC, Saunders DL, Wojnarski M. Piperaquine resistant Cambodian Plasmodium falciparum clinical isolates: in vitro genotypic and phenotypic characterization. Malar J 2020; 19:269. [PMID: 32711538 PMCID: PMC7382038 DOI: 10.1186/s12936-020-03339-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND High rates of dihydroartemisinin-piperaquine (DHA-PPQ) treatment failures have been documented for uncomplicated Plasmodium falciparum in Cambodia. The genetic markers plasmepsin 2 (pfpm2), exonuclease (pfexo) and chloroquine resistance transporter (pfcrt) genes are associated with PPQ resistance and are used for monitoring the prevalence of drug resistance and guiding malaria drug treatment policy. METHODS To examine the relative contribution of each marker to PPQ resistance, in vitro culture and the PPQ survival assay were performed on seventeen P. falciparum isolates from northern Cambodia, and the presence of E415G-Exo and pfcrt mutations (T93S, H97Y, F145I, I218F, M343L, C350R, and G353V) as well as pfpm2 copy number polymorphisms were determined. Parasites were then cloned by limiting dilution and the cloned parasites were tested for drug susceptibility. Isobolographic analysis of several drug combinations for standard clones and newly cloned P. falciparum Cambodian isolates was also determined. RESULTS The characterization of culture-adapted isolates revealed that the presence of novel pfcrt mutations (T93S, H97Y, F145I, and I218F) with E415G-Exo mutation can confer PPQ-resistance, in the absence of pfpm2 amplification. In vitro testing of PPQ resistant parasites demonstrated a bimodal dose-response, the existence of a swollen digestive vacuole phenotype, and an increased susceptibility to quinine, chloroquine, mefloquine and lumefantrine. To further characterize drug sensitivity, parental parasites were cloned in which a clonal line, 14-B5, was identified as sensitive to artemisinin and piperaquine, but resistant to chloroquine. Assessment of the clone against a panel of drug combinations revealed antagonistic activity for six different drug combinations. However, mefloquine-proguanil and atovaquone-proguanil combinations revealed synergistic antimalarial activity. CONCLUSIONS Surveillance for PPQ resistance in regions relying on DHA-PPQ as the first-line treatment is dependent on the monitoring of molecular markers of drug resistance. P. falciparum harbouring novel pfcrt mutations with E415G-exo mutations displayed PPQ resistant phenotype. The presence of pfpm2 amplification was not required to render parasites PPQ resistant suggesting that the increase in pfpm2 copy number alone is not the sole modulator of PPQ resistance. Genetic background of circulating field isolates appear to play a role in drug susceptibility and biological responses induced by drug combinations. The use of latest field isolates may be necessary for assessment of relevant drug combinations against P. falciparum strains and when down-selecting novel drug candidates.
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Affiliation(s)
- Nonlawat Boonyalai
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Brian A Vesely
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chatchadaporn Thamnurak
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chantida Praditpol
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Watcharintorn Fagnark
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Kirakarn Kirativanich
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Piyaporn Saingam
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chaiyaporn Chaisatit
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Paphavee Lertsethtakarn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Panita Gosi
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Worachet Kuntawunginn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Pattaraporn Vanachayangkul
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Michele D Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Mark M Fukuda
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chanthap Lon
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Philip L Smith
- Walter Reed Army Institute of Research, Silver Spring, Maryland, 20910, USA
| | - Norman C Waters
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - David L Saunders
- U.S. Army Research Institute of Infectious Diseases, Frederick, MD, USA
| | - Mariusz Wojnarski
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
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16
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Riegel B, Roepe PD. Altered Drug Transport by Plasmodium falciparum Chloroquine Resistance Transporter Isoforms Harboring Mutations Associated with Piperaquine Resistance. Biochemistry 2020; 59:2484-2493. [DOI: 10.1021/acs.biochem.0c00247] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bryce Riegel
- Department of Chemistry and Department of Biochemistry and Cellular and Molecular Biology, Georgetown University, Washington, D.C. 20057, United States
| | - Paul D. Roepe
- Department of Chemistry and Department of Biochemistry and Cellular and Molecular Biology, Georgetown University, Washington, D.C. 20057, United States
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17
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Ansbro MR, Jacob CG, Amato R, Kekre M, Amaratunga C, Sreng S, Suon S, Miotto O, Fairhurst RM, Wellems TE, Kwiatkowski DP. Development of copy number assays for detection and surveillance of piperaquine resistance associated plasmepsin 2/3 copy number variation in Plasmodium falciparum. Malar J 2020; 19:181. [PMID: 32404110 PMCID: PMC7218657 DOI: 10.1186/s12936-020-03249-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/29/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Long regarded as an epicenter of drug-resistant malaria, Southeast Asia continues to provide new challenges to the control of Plasmodium falciparum malaria. Recently, resistance to the artemisinin combination therapy partner drug piperaquine has been observed in multiple locations across Southeast Asia. Genetic studies have identified single nucleotide polymorphisms as well as copy number variations in the plasmepsin 2 and plasmepsin 3 genes, which encode haemoglobin-degrading proteases that associate with clinical and in vitro piperaquine resistance. RESULTS To accurately and quickly determine the presence of copy number variations in the plasmepsin 2/3 genes in field isolates, this study developed a quantitative PCR assay using TaqMan probes. Copy number estimates were validated using a separate SYBR green-based quantitative PCR assay as well as a novel PCR-based breakpoint assay to detect the hybrid gene product. Field samples from 2012 to 2015 across three sites in Cambodia were tested using DNA extracted from dried blood spots and whole blood to monitor the extent of plasmepsin 2/3 gene amplifications, as well as amplifications in the multidrug resistance transporter 1 gene (pfmdr1), a marker of mefloquine resistance. This study found high concordance across all methods of copy number detection. For samples derived from dried blood spots, a success rate greater than 80% was found in each assay, with more recent samples performing better. Evidence of extensive plasmepsin 2/3 copy number amplifications was observed in Pursat (94%, 2015) (Western Cambodia) and Preah Vihear (87%, 2014) (Northern Cambodia), and lower levels in Ratanakiri (16%, 2014) (Eastern Cambodia). A shift was observed from two copies of plasmepsin 2 in Pursat in 2013 to three copies in 2014-2015 (25% to 64%). Pfmdr1 amplifications were absent in all samples from Preah Vihear and Ratanakiri in 2014 and absent in Pursat in 2015. CONCLUSIONS The multiplex TaqMan assay is a robust tool for monitoring both plasmepsin 2/3 and pfmdr1 copy number variations in field isolates, and the SYBR-green and breakpoint assays are useful for monitoring plasmepsin 2/3 amplifications. This study shows increasing levels of plasmepsin 2 copy numbers across Cambodia from 2012 to 2015 and a complete reversion of multicopy pfmdr1 parasites to single copy parasites in all study locations.
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Affiliation(s)
- Megan R Ansbro
- Wellcome Sanger Institute, Hinxton, UK.
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA.
| | | | | | | | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Sokunthea Sreng
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Olivo Miotto
- Wellcome Sanger Institute, Hinxton, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Genomics and Global Health, Wellcome Centre for Human Genetics, Oxford, UK
| | - Rick M Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Thomas E Wellems
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Dominic P Kwiatkowski
- Wellcome Sanger Institute, Hinxton, UK
- Centre for Genomics and Global Health, Wellcome Centre for Human Genetics, Oxford, UK
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18
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Li Y, Shetty AC, Lon C, Spring M, Saunders DL, Fukuda MM, Hien TT, Pukrittayakamee S, Fairhurst RM, Dondorp AM, Plowe CV, O’Connor TD, Takala-Harrison S, Stewart K. Detecting geospatial patterns of Plasmodium falciparum parasite migration in Cambodia using optimized estimated effective migration surfaces. Int J Health Geogr 2020; 19:13. [PMID: 32276636 PMCID: PMC7149848 DOI: 10.1186/s12942-020-00207-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/01/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Understanding the genetic structure of natural populations provides insight into the demographic and adaptive processes that have affected those populations. Such information, particularly when integrated with geospatial data, can have translational applications for a variety of fields, including public health. Estimated effective migration surfaces (EEMS) is an approach that allows visualization of the spatial patterns in genomic data to understand population structure and migration. In this study, we developed a workflow to optimize the resolution of spatial grids used to generate EEMS migration maps and applied this optimized workflow to estimate migration of Plasmodium falciparum in Cambodia and bordering regions of Thailand and Vietnam. METHODS The optimal density of EEMS grids was determined based on a new workflow created using density clustering to define genomic clusters and the spatial distance between genomic clusters. Topological skeletons were used to capture the spatial distribution for each genomic cluster and to determine the EEMS grid density; i.e., both genomic and spatial clustering were used to guide the optimization of EEMS grids. Model accuracy for migration estimates using the optimized workflow was tested and compared to grid resolutions selected without the optimized workflow. As a test case, the optimized workflow was applied to genomic data generated from P. falciparum sampled in Cambodia and bordering regions, and migration maps were compared to estimates of malaria endemicity, as well as geographic properties of the study area, as a means of validating observed migration patterns. RESULTS Optimized grids displayed both high model accuracy and reduced computing time compared to grid densities selected in an unguided manner. In addition, EEMS migration maps generated for P. falciparum using the optimized grid corresponded to estimates of malaria endemicity and geographic properties of the study region that might be expected to impact malaria parasite migration, supporting the validity of the observed migration patterns. CONCLUSIONS Optimized grids reduce spatial uncertainty in the EEMS contours that can result from user-defined parameters, such as the resolution of the spatial grid used in the model. This workflow will be useful to a broad range of EEMS users as it can be applied to analyses involving other organisms of interest and geographic areas.
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Affiliation(s)
- Yao Li
- Center for Geospatial Information Science, Department of Geographical Sciences, University of Maryland, College Park, 20742 MD USA
| | - Amol C. Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, 21201 MD USA
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Michele Spring
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - David L. Saunders
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mark M. Fukuda
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Timothy D. O’Connor
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, 21201 MD USA
| | - Shannon Takala-Harrison
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, 21201 MD USA
| | - Kathleen Stewart
- Center for Geospatial Information Science, Department of Geographical Sciences, University of Maryland, College Park, 20742 MD USA
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19
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Balasubramanian S, Rahman RS, Lon C, Parobek C, Ubalee R, Hathaway N, Kuntawunginn W, My M, Vy D, Saxe J, Lanteri C, Lin FC, Spring M, Meshnick SR, Juliano JJ, Saunders DL, Lin JT. Efficient Transmission of Mixed Plasmodium falciparum/vivax Infections From Humans to Mosquitoes. J Infect Dis 2020; 221:428-437. [PMID: 31549156 PMCID: PMC7184918 DOI: 10.1093/infdis/jiz388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In Southeast Asia, people are often coinfected with different species of malaria (Plasmodium falciparum [Pf] and Plasmodium vivax [Pv]) as well as with multiple clones of the same species. Whether particular species or clones within mixed infections are more readily transmitted to mosquitoes remains unknown. METHODS Laboratory-reared Anopheles dirus were fed on blood from 119 Pf-infected Cambodian adults, with 5950 dissected to evaluate for transmitted infection. Among 12 persons who infected mosquitoes, polymerase chain reaction and amplicon deep sequencing were used to track species and clone-specific transmission to mosquitoes. RESULTS Seven of 12 persons that infected mosquitoes harbored mixed Pf/Pv infection. Among these 7 persons, all transmitted Pv with 2 transmitting both Pf and Pv, leading to Pf/Pv coinfection in 21% of infected mosquitoes. Up to 4 clones of each species were detected within persons. Shifts in clone frequency were detected during transmission. However, in general, all parasite clones in humans were transmitted to mosquitoes, with individual mosquitoes frequently carrying multiple transmitted clones. CONCLUSIONS Malaria diversity in human hosts was maintained in the parasite populations recovered from mosquitoes fed on their blood. However, in persons with mixed Pf/Pv malaria, Pv appears to be transmitted more readily, in association with more prevalent patent gametocytemia.
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Affiliation(s)
- Sujata Balasubramanian
- Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill
| | - Rifat S Rahman
- Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Christian Parobek
- Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill
| | - Ratawan Ubalee
- Department of Entomology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Nicholas Hathaway
- Department of Bioinformatics and Integrated Biology, University of Massachusetts, Worcester
| | - Worachet Kuntawunginn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mok My
- Royal Cambodian Armed Forces, Phnom Penh, Cambodia
| | - Dav Vy
- Royal Cambodian Armed Forces, Phnom Penh, Cambodia
| | - Jeremy Saxe
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Charlotte Lanteri
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Michele Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Jonathan J Juliano
- Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill
| | - David L Saunders
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
- US Army Medical Materiel Development Activity, Fort Detrick, Maryland
| | - Jessica T Lin
- Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill
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20
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Conrad MD, Rosenthal PJ. Antimalarial drug resistance in Africa: the calm before the storm? THE LANCET. INFECTIOUS DISEASES 2019; 19:e338-e351. [DOI: 10.1016/s1473-3099(19)30261-0] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/09/2019] [Accepted: 05/09/2019] [Indexed: 11/26/2022]
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21
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Lin JT, Patel JC, Levitz L, Wojnarski M, Chaorattanakawee S, Gosi P, Buathong N, Chann S, Huy R, Thay K, Sea D, Samon N, Takala-Harrison S, Fukuda M, Smith P, Spring M, Saunders D, Lon C. Gametocyte Carriage, Antimalarial Use, and Drug Resistance in Cambodia, 2008-2014. Am J Trop Med Hyg 2019; 99:1145-1149. [PMID: 30226145 DOI: 10.4269/ajtmh.18-0509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Gametocytes are the malaria parasite stages responsible for transmission from humans to mosquitoes. Gametocytemia often follows drug treatment, especially as therapies start to fail. We examined Plasmodium falciparum gametocyte carriage and drug resistance profiles among 824 persons with uncomplicated malaria in Cambodia to determine whether prevalent drug resistance and antimalarial use has led to a concentration of drug-resistant parasites among gametocyte carriers. Although report of prior antimalarial use increased from 2008 to 2014, the prevalence of study participants presenting with microscopic gametocyte carriage declined. Gametocytemia was more common in those reporting antimalarial use within the past year, and prior antimalarial use was correlated with higher IC50s to piperaquine and mefloquine, as well as to increased pfmdr1 copy number. However, there was no association between microscopic gametocyte carriage and parasite drug resistance. Thus, we found no evidence that the infectious reservoir, marked by those carrying gametocytes, is enriched with drug-resistant parasites.
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Affiliation(s)
- Jessica T Lin
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jaymin C Patel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Levitz
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Mariusz Wojnarski
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Suwanna Chaorattanakawee
- Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Panita Gosi
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Nillawan Buathong
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Soklyda Chann
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Rekol Huy
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Khengheng Thay
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Darapiseth Sea
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Nou Samon
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Shannon Takala-Harrison
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mark Fukuda
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Philip Smith
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Michele Spring
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - David Saunders
- U.S. Army Medical Materiel Development Activity, Fort Detrick, Maryland
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
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22
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Wojnarski M, Lon C, Vanachayangkul P, Gosi P, Sok S, Rachmat A, Harrison D, Berjohn CM, Spring M, Chaoratanakawee S, Ittiverakul M, Buathong N, Chann S, Wongarunkochakorn S, Waltmann A, Kuntawunginn W, Fukuda MM, Burkly H, Heang V, Heng TK, Kong N, Boonchan T, Chum B, Smith P, Vaughn A, Prom S, Lin J, Lek D, Saunders D. Atovaquone-Proguanil in Combination With Artesunate to Treat Multidrug-Resistant P. falciparum Malaria in Cambodia: An Open-Label Randomized Trial. Open Forum Infect Dis 2019; 6:ofz314. [PMID: 31660398 DOI: 10.1093/ofid/ofz314] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/28/2019] [Indexed: 12/16/2022] Open
Abstract
Background Recent artemisinin-combination therapy failures in Cambodia prompted a search for alternatives. Atovaquone-proguanil (AP), a safe, effective treatment for multidrug-resistant Plasmodium falciparum (P.f.), previously demonstrated additive effects in combination with artesunate (AS). Methods Patients with P.f. or mixed-species infection (n = 205) in Anlong Veng (AV; n = 157) and Kratie (KT; n = 48), Cambodia, were randomized open-label 1:1 to a fixed-dose 3-day AP regimen +/-3 days of co-administered artesunate (ASAP). Single low-dose primaquine (PQ, 15 mg) was given on day 1 to prevent gametocyte-mediated transmission. Results Polymerase chain reaction-adjusted adequate clinical and parasitological response at 42 days was 90% for AP (95% confidence interval [CI], 82%-95%) and 92% for ASAP (95% CI, 83%-96%; P = .73). The median parasite clearance time was 72 hours for ASAP in AV vs 56 hours in KT (P < .001) and was no different than AP alone. At 1 week postprimaquine, 7% of the ASAP group carried microscopic gametocytes vs 29% for AP alone (P = .0001). Nearly all P.f. isolates had C580Y K13 propeller artemisinin resistance mutations (AV 99%; KT 88%). Only 1 of 14 treatment failures carried the cytochrome bc1 (Pfcytb) atovaquone resistance mutation, which was not present at baseline. P.f. isolates remained atovaquone sensitive in vitro but cycloguanil resistant, with a triple P.f. dihydrofolate reductase mutation. Conclusions Atovaquone-proguanil remained marginally effective in Cambodia (≥90%) with minimal Pfcytb mutations observed. Treatment failures in the presence of ex vivo atovaquone sensitivity and adequate plasma levels may be attributable to cycloguanil and/or artemisinin resistance. Artesunate co-administration provided little additional blood-stage efficacy but reduced post-treatment gametocyte carriage in combination with AP beyond single low-dose primaquine.
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Affiliation(s)
- Mariusz Wojnarski
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Chanthap Lon
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Panita Gosi
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Somethy Sok
- Department of Health, Ministry of National Defense, Phnom Penh, Cambodia
| | - Agus Rachmat
- Naval Medical Research Unit-2, Phnom Penh, Cambodia
| | | | | | - Michele Spring
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.,Henry M. Jackson Foundation, Bethesda, Maryland
| | - Suwanna Chaoratanakawee
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.,Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mali Ittiverakul
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Nillawan Buathong
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Soklyda Chann
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | | | - Mark M Fukuda
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Hana Burkly
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Vireak Heang
- Naval Medical Research Unit-2, Phnom Penh, Cambodia
| | - Thay Keang Heng
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Nareth Kong
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Threechada Boonchan
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Bolin Chum
- Naval Medical Research Unit-2, Phnom Penh, Cambodia
| | - Philip Smith
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Satharath Prom
- Department of Health, Ministry of National Defense, Phnom Penh, Cambodia
| | - Jessica Lin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina
| | - Dysoley Lek
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - David Saunders
- US Army Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.,US Army Medical Materiel Development Activity, Fort Detrick, Maryland
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23
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Shetty AC, Jacob CG, Huang F, Li Y, Agrawal S, Saunders DL, Lon C, Fukuda MM, Ringwald P, Ashley EA, Han KT, Hlaing TM, Nyunt MM, Silva JC, Stewart KE, Plowe CV, O'Connor TD, Takala-Harrison S. Genomic structure and diversity of Plasmodium falciparum in Southeast Asia reveal recent parasite migration patterns. Nat Commun 2019; 10:2665. [PMID: 31209259 PMCID: PMC6572796 DOI: 10.1038/s41467-019-10121-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 04/17/2019] [Indexed: 02/08/2023] Open
Abstract
Estimates of Plasmodium falciparum migration may inform strategies for malaria elimination. Here we elucidate fine-scale parasite population structure and infer recent migration across Southeast Asia using identity-by-descent (IBD) approaches based on genome-wide single nucleotide polymorphisms called in 1722 samples from 54 districts. IBD estimates are consistent with isolation-by-distance. We observe greater sharing of larger IBD segments between artemisinin-resistant parasites versus sensitive parasites, which is consistent with the recent spread of drug resistance. Our IBD analyses reveal actionable patterns, including isolated parasite populations, which may be prioritized for malaria elimination, as well as asymmetrical migration identifying potential sources and sinks of migrating parasites.
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Affiliation(s)
- Amol C Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Graduate Program in Epidemiology and Human Genetics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | | | - Fang Huang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Beijing, 102206, PR China
| | - Yao Li
- Center for Geospatial Information Science, University of Maryland, College Park, MD, 20742, USA
| | - Sonia Agrawal
- Graduate Program in Epidemiology and Human Genetics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - David L Saunders
- Armed Forces Research Institute of Medical Sciences, Bangkok, 10400, Thailand
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Khan Daun Penh, Phnom Penh, Cambodia
| | - Mark M Fukuda
- Armed Forces Research Institute of Medical Sciences, Bangkok, 10400, Thailand
| | - Pascal Ringwald
- Global Malaria Programme, World Health Organization, Geneva, 1202, Switzerland
| | - Elizabeth A Ashley
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Kay Thwe Han
- Department of Medical Research, Ministry of Health and Sports, Yangon, 11191, Myanmar
| | | | - Myaing M Nyunt
- Duke Global Health Institute, Duke University, Durham, NC, 27710, USA
| | - Joana C Silva
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Kathleen E Stewart
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | | | - Timothy D O'Connor
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Program in Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Shannon Takala-Harrison
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
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24
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Zainabadi K, Nyunt MM, Plowe CV. An improved nucleic acid extraction method from dried blood spots for amplification of Plasmodium falciparum kelch13 for detection of artemisinin resistance. Malar J 2019; 18:192. [PMID: 31185976 PMCID: PMC6558694 DOI: 10.1186/s12936-019-2817-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/18/2019] [Indexed: 12/15/2022] Open
Abstract
Background Mutational analysis of the Plasmodium falciparum kelch 13 (k13) gene is routinely performed to track the emergence and spread of artemisinin resistance. Surveillance of resistance markers has been impeded by the difficulty of extracting sufficient DNA from low parasite density infections common in low-transmission settings, such as Southeast Asia. This problem can be overcome by collecting large volumes of venous blood. Efficient methods for extracting and amplifying k13 from dried blood spots (DBS) would facilitate resistance surveillance. Methods Methods for k13 amplification from standard Whatman 3MM DBS (stored for 14 days at 28 °C with 80% relative humidity) were optimized by systematically testing different extraction conditions. Conditions that improved parasite DNA recovery as assessed by quantitative polymerase chain reaction (PCR) of 18S rDNA were then tested for their impact on k13 PCR amplification. Results The optimized protocol for amplification of k13 from DBS is markedly more sensitive than standard methods using commercial kits. Using this method, k13 was successfully amplified from laboratory-created DBS samples with parasite densities as low as 500 parasites/mL. Importantly, the method recovers both DNA and RNA, making it compatible with RNA-based ultrasensitive techniques currently in use. Conclusions The optimized DBS protocol should facilitate drug resistance surveillance, especially in low-transmission settings where clinical malaria infections with high parasite densities are rare. Electronic supplementary material The online version of this article (10.1186/s12936-019-2817-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kayvan Zainabadi
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA. .,Center for Global Health, Weill Cornell Medicine, New York, NY, USA.
| | - Myaing M Nyunt
- Duke Global Health Institute, Duke University, Durham, NC, USA
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25
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Dhingra SK, Gabryszewski SJ, Small-Saunders JL, Yeo T, Henrich PP, Mok S, Fidock DA. Global Spread of Mutant PfCRT and Its Pleiotropic Impact on Plasmodium falciparum Multidrug Resistance and Fitness. mBio 2019; 10:e02731-18. [PMID: 31040246 PMCID: PMC6495381 DOI: 10.1128/mbio.02731-18] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/25/2019] [Indexed: 12/12/2022] Open
Abstract
The global spread of Plasmodium falciparum chloroquine resistance transporter (PfCRT) variant haplotypes earlier caused the widespread loss of chloroquine (CQ) efficacy. In Asia, novel PfCRT mutations that emerged on the Dd2 allelic background have recently been implicated in high-level resistance to piperaquine, and N326S and I356T have been associated with genetic backgrounds in which resistance emerged to artemisinin derivatives. By analyzing large-scale genome sequencing data, we report that the predominant Asian CQ-resistant Dd2 haplotype is undetectable in Africa. Instead, the GB4 and previously unexplored Cam783 haplotypes predominate, along with wild-type, drug-sensitive PfCRT that has reemerged as the major haplotype. To interrogate how these alleles impact drug susceptibility, we generated pfcrt-modified isogenic parasite lines spanning the mutational interval between GB4 and Dd2, which includes Cam783 and involves amino acid substitutions at residues 326 and 356. Relative to Dd2, the GB4 and Cam783 alleles were observed to mediate lower degrees of resistance to CQ and the first-line drug amodiaquine, while resulting in higher growth rates. These findings suggest that differences in growth rates, a surrogate of parasite fitness, influence selection in the context of African infections that are frequently characterized by high transmission rates, mixed infections, increased immunity, and less recourse to treatment. We also observe that the Asian Dd2 allele affords partial protection against piperaquine yet does not directly impact artemisinin efficacy. Our results can help inform the regional recommendations of antimalarials, whose activity is influenced by and, in certain cases, enhanced against select PfCRT variant haplotypes.IMPORTANCE Our study defines the allelic distribution of pfcrt, an important mediator of multidrug resistance in Plasmodium falciparum, in Africa and Asia. We leveraged whole-genome sequence analysis and gene editing to demonstrate how current drug combinations can select different allelic variants of this gene and shape region-specific parasite population structures. We document the ability of PfCRT mutations to modulate parasite susceptibility to current antimalarials in dissimilar, pfcrt allele-specific ways. This study underscores the importance of actively monitoring pfcrt genotypes to identify emerging patterns of multidrug resistance and help guide region-specific treatment options.
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Affiliation(s)
- Satish K Dhingra
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
| | - Stanislaw J Gabryszewski
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer L Small-Saunders
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Tomas Yeo
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
| | - Philipp P Henrich
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sachel Mok
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
| | - David A Fidock
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
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26
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Metabolism of Piperaquine to Its Antiplasmodial Metabolites and Their Pharmacokinetic Profiles in Healthy Volunteers. Antimicrob Agents Chemother 2018; 62:AAC.00260-18. [PMID: 29784841 DOI: 10.1128/aac.00260-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/18/2018] [Indexed: 12/19/2022] Open
Abstract
As a partner antimalarial for artemisinin drug-based combination therapy (ACT), piperaquine (PQ) can be metabolized into two major metabolites, including piperaquine N-oxide (M1) and piperaquine N,N-dioxide (M2). To better understand the antimalarial potency of PQ, the antimalarial activity of the PQ metabolites (M1 and M2) was studied in vitro (in Plasmodium falciparum strains Pf3D7 and PfDd2) and in vivo (in the murine species Plasmodium yoelii) in this study. The recrudescence and survival time of infected mice were also recorded after drug treatment. The pharmacokinetic profiles of PQ and its two metabolites (M1 and M2) were investigated in healthy subjects after oral doses of two widely used ACT regimens, i.e., dihydroartemisinin plus piperaquine phosphate (Duo-Cotecxin) and artemisinin plus piperaquine (Artequick). Remarkable antiplasmodial activity was found for PQ (50% growth-inhibitory concentration [IC50], 4.5 nM against Pf3D7 and 6.9 nM against PfDd2; 90% effective dose [ED90], 1.3 mg/kg of body weight), M1 (IC50, 25.5 nM against Pf3D7 and 38.7 nM against PfDd2; ED90, 1.3 mg/kg), and M2 (IC50, 31.2 nM against Pf3D7 and 33.8 nM against PfDd2; ED90, 2.9 mg/kg). Compared with PQ, M1 showed comparable efficacy in terms of recrudescence and survival time and M2 had relatively weaker antimalarial potency. PQ and its two metabolites displayed a long elimination half-life (∼11 days for PQ, ∼9 days for M1, and ∼4 days for M2), and they accumulated after repeated administrations. The contribution of the two PQ metabolites to the efficacy of piperaquine as a partner drug of ACT for the treatment of malaria should be considered for PQ dose optimization.
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27
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Bopp S, Magistrado P, Wong W, Schaffner SF, Mukherjee A, Lim P, Dhorda M, Amaratunga C, Woodrow CJ, Ashley EA, White NJ, Dondorp AM, Fairhurst RM, Ariey F, Menard D, Wirth DF, Volkman SK. Plasmepsin II-III copy number accounts for bimodal piperaquine resistance among Cambodian Plasmodium falciparum. Nat Commun 2018; 9:1769. [PMID: 29720620 PMCID: PMC5931971 DOI: 10.1038/s41467-018-04104-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 03/30/2018] [Indexed: 12/30/2022] Open
Abstract
Multidrug resistant Plasmodium falciparum in Southeast Asia endangers regional malaria elimination and threatens to spread to other malaria endemic areas. Understanding mechanisms of piperaquine (PPQ) resistance is crucial for tracking its emergence and spread, and to develop effective strategies for overcoming it. Here we analyze a mechanism of PPQ resistance in Cambodian parasites. Isolates exhibit a bimodal dose-response curve when exposed to PPQ, with the area under the curve quantifying their survival in vitro. Increased copy number for plasmepsin II and plasmepsin III appears to explain enhanced survival when exposed to PPQ in most, but not all cases. A panel of isogenic subclones reinforces the importance of plasmepsin II-III copy number to enhanced PPQ survival. We conjecture that factors producing increased parasite survival under PPQ exposure in vitro may drive clinical PPQ failures in the field.
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Affiliation(s)
- Selina Bopp
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | | | - Wesley Wong
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Stephen F Schaffner
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Angana Mukherjee
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Pharath Lim
- National Institutes of Health, Rockville, MD, 20892, USA
| | - Mehul Dhorda
- Worldwide Antimalarial Resistance Network, Bangkok, 10400, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | | | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | - Elizabeth A Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | | | - Frederic Ariey
- Institut Cochin, INSERM U:1016, Parasitology-Mycology Unit, Cochin Hospital Paris Descartes University, Paris, 75014, France
| | - Didier Menard
- Biology of Host-Parasite Interactions Unit, Institut Pasteur, Paris, 75015, France
- CNRS, ERL 9195, Paris, 75794, France
- INSERM, Unit U1201, Paris, 75015, France
| | - Dyann F Wirth
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Sarah K Volkman
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA.
- Simmons College, Boston, MA, 02115, USA.
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28
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Parobek CM, Parr JB, Brazeau NF, Lon C, Chaorattanakawee S, Gosi P, Barnett EJ, Norris LD, Meshnick SR, Spring MD, Lanteri CA, Bailey JA, Saunders DL, Lin JT, Juliano JJ. Partner-Drug Resistance and Population Substructuring of Artemisinin-Resistant Plasmodium falciparum in Cambodia. Genome Biol Evol 2018; 9:1673-1686. [PMID: 28854635 PMCID: PMC5522704 DOI: 10.1093/gbe/evx126] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2017] [Indexed: 12/13/2022] Open
Abstract
Plasmodium falciparum in western Cambodia has developed resistance to artemisinin and its partner drugs, causing frequent treatment failure. Understanding this evolution can inform the deployment of new therapies. We investigated the genetic architecture of 78 falciparum isolates using whole-genome sequencing, correlating results to in vivo and ex vivo drug resistance and exploring the relationship between population structure, demographic history, and partner drug resistance. Principle component analysis, network analysis and demographic inference identified a diverse central population with three clusters of clonally expanding parasite populations, each associated with specific K13 artemisinin resistance alleles and partner drug resistance profiles which were consistent with the sequential deployment of artemisinin combination therapies in the region. One cluster displayed ex vivo piperaquine resistance and mefloquine sensitivity with a high rate of in vivo failure of dihydroartemisinin-piperaquine. Another cluster displayed ex vivo mefloquine resistance and piperaquine sensitivity with high in vivo efficacy of dihydroartemisinin-piperaquine. The final cluster was clonal and displayed intermediate sensitivity to both drugs. Variations in recently described piperaquine resistance markers did not explain the difference in mean IC90 or clinical failures between the high and intermediate piperaquine resistance groups, suggesting additional loci may be involved in resistance. The results highlight an important role for partner drug resistance in shaping the P. falciparum genetic landscape in Southeast Asia and suggest that further work is needed to evaluate for other mutations that drive piperaquine resistance.
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Affiliation(s)
- Christian M Parobek
- Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill
| | - Jonathan B Parr
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Chanthap Lon
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Suwanna Chaorattanakawee
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Panita Gosi
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Eric J Barnett
- School of Medicine, Upstate Medical University, State University of New York, Syracuse
| | - Lauren D Norris
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Michele D Spring
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Charlotte A Lanteri
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Jeffrey A Bailey
- Program in Bioinformatics and Integrative Biology, Division of Transfusion Medicine, University of Massachusetts Medical School
| | - David L Saunders
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Jessica T Lin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
| | - Jonathan J Juliano
- Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill.,Division of Infectious Diseases, University of North Carolina, Chapel Hill.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
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29
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Abstract
Resistance to first-line treatments for Plasmodium falciparum malaria and the insecticides used for Anopheles vector control are threatening malaria elimination efforts. Suboptimal responses to drugs and insecticides are both spreading geographically and emerging independently and are being seen at increasing intensities. Whilst resistance is unavoidable, its effects can be mitigated through resistance management practices, such as exposing the parasite or vector to more than one selective agent. Resistance contributed to the failure of the 20th century Global Malaria Eradication Programme, and yet the global response to this issue continues to be slow and poorly coordinated-too often, too little, too late. The Malaria Eradication Research Agenda (malERA) Refresh process convened a panel on resistance of both insecticides and antimalarial drugs. This paper outlines developments in the field over the past 5 years, highlights gaps in knowledge, and proposes a research agenda focused on managing resistance. A deeper understanding of the complex biological processes involved and how resistance is selected is needed, together with evidence of its public health impact. Resistance management will require improved use of entomological and parasitological data in decision making, and optimisation of the useful life of new and existing products through careful implementation, combination, and evaluation. A proactive, collaborative approach is needed from basic science and the development of new tools to programme and policy interventions that will ensure that the armamentarium of drugs and insecticides is sufficient to deal with the challenges of malaria control and its elimination.
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30
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Chaorattanakawee S, Lon C, Chann S, Thay KH, Kong N, You Y, Sundrakes S, Thamnurak C, Chattrakarn S, Praditpol C, Yingyuen K, Wojnarski M, Huy R, Spring MD, Walsh DS, Patel JC, Lin J, Juliano JJ, Lanteri CA, Saunders DL. Measuring ex vivo drug susceptibility in Plasmodium vivax isolates from Cambodia. Malar J 2017; 16:392. [PMID: 28964258 PMCID: PMC5622433 DOI: 10.1186/s12936-017-2034-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/19/2017] [Indexed: 12/24/2022] Open
Abstract
Background While intensive Plasmodium falciparum multidrug resistance surveillance continues in Cambodia, relatively little is known about Plasmodium vivax drug resistance in Cambodia or elsewhere. To investigate P. vivax anti-malarial susceptibility in Cambodia, 76 fresh P. vivax isolates collected from Oddar Meanchey (northern Cambodia) in 2013–2015 were assessed for ex vivo drug susceptibility using the microscopy-based schizont maturation test (SMT) and a Plasmodium pan-species lactate dehydrogenase (pLDH) ELISA. P. vivax multidrug resistance gene 1 (pvmdr1) mutations, and copy number were analysed in a subset of isolates. Results Ex vivo testing was interpretable in 80% of isolates using the pLDH-ELISA, but only 25% with the SMT. Plasmodium vivax drug susceptibility by pLDH-ELISA was directly compared with 58 P. falciparum isolates collected from the same locations in 2013–4, tested by histidine-rich protein-2 ELISA. Median pLDH-ELISA IC50 of P. vivax isolates was significantly lower for dihydroartemisinin (3.4 vs 6.3 nM), artesunate (3.2 vs 5.7 nM), and chloroquine (22.1 vs 103.8 nM) than P. falciparum but higher for mefloquine (92 vs 66 nM). There were not significant differences for lumefantrine or doxycycline. Both P. vivax and P. falciparum had comparable median piperaquine IC50 (106.5 vs 123.8 nM), but some P. falciparum isolates were able to grow in much higher concentrations above the normal standard range used, attaining up to 100-fold greater IC50s than P. vivax. A high percentage of P. vivax isolates had pvmdr1 Y976F (78%) and F1076L (83%) mutations but none had pvmdr1 amplification. Conclusion The findings of high P. vivax IC50 to mefloquine and piperaquine, but not chloroquine, suggest significant drug pressure from drugs used to treat multidrug resistant P. falciparum in Cambodia. Plasmodium vivax isolates are frequently exposed to mefloquine and piperaquine due to mixed infections and the long elimination half-life of these drugs. Difficulty distinguishing infection due to relapsing hypnozoites versus blood-stage recrudescence complicates clinical detection of P. vivax resistance, while well-validated molecular markers of chloroquine resistance remain elusive. The pLDH assay may be a useful adjunctive tool for monitoring for emerging drug resistance, though more thorough validation is needed. Given high grade clinical chloroquine resistance observed recently in neighbouring countries, low chloroquine IC50 values seen here should not be interpreted as susceptibility in the absence of clinical data. Incorporating pLDH monitoring with therapeutic efficacy studies for individuals with P. vivax will help to further validate this field-expedient method. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2034-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Suwanna Chaorattanakawee
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand. .,Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand.
| | - Chanthap Lon
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Soklyda Chann
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Kheang Heng Thay
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Nareth Kong
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Yom You
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Siratchana Sundrakes
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Chatchadaporn Thamnurak
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Sorayut Chattrakarn
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Chantida Praditpol
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Kritsanai Yingyuen
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Mariusz Wojnarski
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Rekol Huy
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Michele D Spring
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Douglas S Walsh
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - Jaymin C Patel
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jessica Lin
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jonathan J Juliano
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Charlotte A Lanteri
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand
| | - David L Saunders
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.,US Army Medical Materiel Development Activity, Fort Detrick, Frederick, MD, USA
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31
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Agrawal S, Moser KA, Morton L, Cummings MP, Parihar A, Dwivedi A, Shetty AC, Drabek EF, Jacob CG, Henrich PP, Parobek CM, Jongsakul K, Huy R, Spring MD, Lanteri CA, Chaorattanakawee S, Lon C, Fukuda MM, Saunders DL, Fidock DA, Lin JT, Juliano JJ, Plowe CV, Silva JC, Takala-Harrison S. Association of a Novel Mutation in the Plasmodium falciparum Chloroquine Resistance Transporter With Decreased Piperaquine Sensitivity. J Infect Dis 2017; 216:468-476. [PMID: 28931241 DOI: 10.1093/infdis/jix334] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022] Open
Abstract
Background Amplified copy number in the plasmepsin II/III genes within Plasmodium falciparum has been associated with decreased sensitivity to piperaquine. To examine this association and test whether additional loci might also contribute, we performed a genome-wide association study of ex vivo P. falciparum susceptibility to piperaquine. Methods Plasmodium falciparum DNA from 183 samples collected primarily from Cambodia was genotyped at 33716 genome-wide single nucleotide polymorphisms (SNPs). Linear mixed models and random forests were used to estimate associations between parasite genotypes and piperaquine susceptibility. Candidate polymorphisms were evaluated for their association with dihydroartemisinin-piperaquine treatment outcomes in an independent dataset. Results Single nucleotide polymorphisms on multiple chromosomes were associated with piperaquine 90% inhibitory concentrations (IC90) in a genome-wide analysis. Fine-mapping of genomic regions implicated in genome-wide analyses identified multiple SNPs in linkage disequilibrium with each other that were significantly associated with piperaquine IC90, including a novel mutation within the gene encoding the P. falciparum chloroquine resistance transporter, PfCRT. This mutation (F145I) was associated with dihydroartemisinin-piperaquine treatment failure after adjusting for the presence of amplified plasmepsin II/III, which was also associated with decreased piperaquine sensitivity. Conclusions Our data suggest that, in addition to plasmepsin II/III copy number, other loci, including pfcrt, may also be involved in piperaquine resistance.
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Affiliation(s)
- Sonia Agrawal
- Division of Malaria Research, Institute for Global Health
| | - Kara A Moser
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
| | - Lindsay Morton
- Division of Malaria Research, Institute for Global Health
| | - Michael P Cummings
- Center for Bioinformatics and Computational Biology, University of Maryland, College Park
| | - Ankita Parihar
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
| | - Ankit Dwivedi
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
| | - Amol C Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
| | - Elliott F Drabek
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
| | | | | | - Christian M Parobek
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Krisada Jongsakul
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - Rekol Huy
- National Center for Parasitology Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Michele D Spring
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - Charlotte A Lanteri
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - Suwanna Chaorattanakawee
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine.,Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences.,Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - Mark M Fukuda
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - David L Saunders
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine
| | - David A Fidock
- Department of Microbiology and Immunology.,Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York
| | - Jessica T Lin
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Jonathan J Juliano
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | | | - Joana C Silva
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
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32
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Mukherjee A, Bopp S, Magistrado P, Wong W, Daniels R, Demas A, Schaffner S, Amaratunga C, Lim P, Dhorda M, Miotto O, Woodrow C, Ashley EA, Dondorp AM, White NJ, Wirth D, Fairhurst R, Volkman SK. Artemisinin resistance without pfkelch13 mutations in Plasmodium falciparum isolates from Cambodia. Malar J 2017; 16:195. [PMID: 28494763 PMCID: PMC5427620 DOI: 10.1186/s12936-017-1845-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/29/2017] [Indexed: 12/31/2022] Open
Abstract
Background Artemisinin resistance is associated with delayed parasite clearance half-life in vivo and correlates with ring-stage survival under dihydroartemisinin in vitro. Both phenotypes are associated with mutations in the PF3D7_1343700 pfkelch13 gene. Recent spread of artemisinin resistance and emerging piperaquine resistance in Southeast Asia show that artemisinin combination therapy, such as dihydroartemisinin–piperaquine, are losing clinical effectiveness, prompting investigation of drug resistance mechanisms and development of strategies to surmount emerging anti-malarial resistance. Methods Sixty-eight parasites isolates with in vivo clearance data were obtained from two Tracking Resistance to Artemisinin Collaboration study sites in Cambodia, culture-adapted, and genotyped for pfkelch13 and other mutations including pfmdr1 copy number; and the RSA0–3h survival rates and response to antimalarial drugs in vitro were measured for 36 of these isolates. Results Among these 36 parasites one isolate demonstrated increased ring-stage survival for a PfKelch13 mutation (D584V, RSA0–3h = 8%), previously associated with slow clearance but not yet tested in vitro. Several parasites exhibited increased ring-stage survival, yet lack pfkelch13 mutations, and one isolate showed evidence for piperaquine resistance. Conclusions This study of 68 culture-adapted Plasmodium falciparum clinical isolates from Cambodia with known clearance values, associated the D584V PfKelch13 mutation with increased ring-stage survival and identified parasites that lack pfkelch13 mutations yet exhibit increased ring-stage survival. These data suggest mutations other than those found in pfkelch13 may be involved in conferring artemisinin resistance in P. falciparum. Piperaquine resistance was also detected among the same Cambodian samples, consistent with reports of emerging piperaquine resistance in the field. These culture-adapted parasites permit further investigation of mechanisms of both artemisinin and piperaquine resistance and development of strategies to prevent or overcome anti-malarial resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1845-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angana Mukherjee
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Selina Bopp
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Pamela Magistrado
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Wesley Wong
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Rachel Daniels
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA.,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Allison Demas
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Stephen Schaffner
- Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Pharath Lim
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Mehul Dhorda
- Asia Regional Centre, Worldwide Antimalarial Resistance Network, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Olivo Miotto
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.,Wellcome Trust Sanger Institute, Hinxton, UK
| | - Charles Woodrow
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Elizabeth A Ashley
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas J White
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Dyann Wirth
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA.,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rick Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Sarah K Volkman
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA. .,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,School of Nursing and Health Sciences, Simmons College, Boston, MA, USA.
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A Variant PfCRT Isoform Can Contribute to Plasmodium falciparum Resistance to the First-Line Partner Drug Piperaquine. mBio 2017; 8:mBio.00303-17. [PMID: 28487425 PMCID: PMC5424201 DOI: 10.1128/mbio.00303-17] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Current efforts to reduce the global burden of malaria are threatened by the rapid spread throughout Asia of Plasmodium falciparum resistance to artemisinin-based combination therapies, which includes increasing rates of clinical failure with dihydroartemisinin plus piperaquine (PPQ) in Cambodia. Using zinc finger nuclease-based gene editing, we report that addition of the C101F mutation to the chloroquine (CQ) resistance-conferring PfCRT Dd2 isoform common to Asia can confer PPQ resistance to cultured parasites. Resistance was demonstrated as significantly higher PPQ concentrations causing 90% inhibition of parasite growth (IC90) or 50% parasite killing (50% lethal dose [LD50]). This mutation also reversed Dd2-mediated CQ resistance, sensitized parasites to amodiaquine, quinine, and artemisinin, and conferred amantadine and blasticidin resistance. Using heme fractionation assays, we demonstrate that PPQ causes a buildup of reactive free heme and inhibits the formation of chemically inert hemozoin crystals. Our data evoke inhibition of heme detoxification in the parasite’s acidic digestive vacuole as the primary mode of both the bis-aminoquinoline PPQ and the related 4-aminoquinoline CQ. Both drugs also inhibit hemoglobin proteolysis at elevated concentrations, suggesting an additional mode of action. Isogenic lines differing in their pfmdr1 copy number showed equivalent PPQ susceptibilities. We propose that mutations in PfCRT could contribute to a multifactorial basis of PPQ resistance in field isolates. The global agenda to eliminate malaria depends on the continued success of artemisinin-based combination therapies (ACTs), which target the asexual blood stages of the intracellular parasite Plasmodium. Partial resistance to artemisinin, however, is now established in Southeast Asia, exposing the partner drugs to increased selective pressure. Plasmodium falciparum resistance to the first-line partner piperaquine (PPQ) is now spreading rapidly in Cambodia, resulting in clinical treatment failures. Here, we report that a variant form of the Plasmodium falciparum chloroquine resistance transporter, harboring a C101F mutation edited into the chloroquine (CQ)-resistant Dd2 isoform prevalent in Asia, can confer PPQ resistance in cultured parasites. This was accompanied by a loss of CQ resistance. Biochemical assays showed that PPQ, like CQ, inhibits the detoxification of reactive heme that is formed by parasite-mediated catabolism of host hemoglobin. We propose that novel PfCRT variants emerging in the field could contribute to a multigenic basis of PPQ resistance.
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Gil JP, Krishna S. pfmdr1 (Plasmodium falciparum multidrug drug resistance gene 1): a pivotal factor in malaria resistance to artemisinin combination therapies. Expert Rev Anti Infect Ther 2017; 15:527-543. [DOI: 10.1080/14787210.2017.1313703] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- J. Pedro Gil
- Physiology and Pharmacology Department, Karolinska Institutet, Stockholm, Sweden
| | - S. Krishna
- St George’s University Hospital, Institute for Infection and Immunity, London, United Kingdom
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35
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Mungthin M, Watanatanasup E, Sitthichot N, Suwandittakul N, Khositnithikul R, Ward SA. Influence of the pfmdr1 Gene on In Vitro Sensitivities of Piperaquine in Thai Isolates of Plasmodium falciparum. Am J Trop Med Hyg 2017; 96:624-629. [PMID: 28044042 DOI: 10.4269/ajtmh.16-0668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Piperaquine combined with dihydroartemisinin is one of the artemisinin derivative combination therapies, which can replace artesunate-mefloquine in treating uncomplicated falciparum malaria in Thailand. The aim of this study was to determine the in vitro sensitivity of Thai Plasmodium falciparum isolates against piperaquine and the influence of the pfmdr1 gene on in vitro response. One hundred and thirty-seven standard laboratory and adapted Thai isolates of P. falciparum were assessed for in vitro piperaquine sensitivity. Polymorphisms of the pfmdr1 gene were determined by polymerase chain reaction methods. The mean and standard deviation of the piperaquine IC50 in Thai isolates of P. falciparum were 16.7 ± 6.3 nM. The parasites exhibiting chloroquine IC50 of ≥ 100 nM were significantly less sensitive to piperaquine compared with the parasite with chloroquine IC50 of < 100 nM. No significant association between the pfmdr1 copy number and piperaquine IC50 values was found. In contrast, the parasites containing the pfmdr1 86Y allele exhibited significantly reduced piperaquine sensitivity. Before nationwide implementation of dihydroartemisinin-piperaquine as the first-line treatment in Thailand, in vitro and in vivo evaluations of this combination should be performed especially in areas where parasites containing the pfmdr1 86Y allele are predominant such as the Thai-Malaysian border.
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Affiliation(s)
- Mathirut Mungthin
- Department of Parasitology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Naruemon Sitthichot
- Department of Parasitology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | | | - Stephen A Ward
- Division of Molecular and Biochemical Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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36
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K13 Propeller Mutations in Plasmodium falciparum Populations in Regions of Malaria Endemicity in Vietnam from 2009 to 2016. Antimicrob Agents Chemother 2017; 61:AAC.01578-16. [PMID: 28137815 PMCID: PMC5365681 DOI: 10.1128/aac.01578-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 01/22/2017] [Indexed: 12/12/2022] Open
Abstract
The spread of artemisinin-resistant Plasmodium falciparum compromises the therapeutic efficacy of artemisinin combination therapies (ACTs) and is considered the greatest threat to current global initiatives to control and eliminate malaria. This is particularly relevant in Vietnam, where dihydroartemisinin-piperaquine (DP) is the recommended ACT for P. falciparum infection. The propeller domain gene of K13, a molecular marker of artemisinin resistance, was successfully sequenced in 1,060 P. falciparum isolates collected at 3 malaria hot spots in Vietnam between 2009 and 2016. Eight K13 propeller mutations (Thr474Ile, Tyr493His, Arg539Thr, Ile543Thr, Pro553Leu, Val568Gly, Pro574Leu, and Cys580Tyr), including several that have been validated to be artemisinin resistance markers, were found. The prevalences of K13 mutations were 29% (222/767), 6% (11/188), and 43% (45/105) in the Binh Phuoc, Ninh Thuan, and Gia Lai Provinces of Vietnam, respectively. Cys580Tyr became the dominant genotype in recent years, with 79.1% (34/43) of isolates in Binh Phuoc Province and 63% (17/27) of isolates in Gia Lai Province carrying this mutation. K13 mutations were associated with reduced ring-stage susceptibility to dihydroartemisinin (DHA) in vitro and prolonged parasite clearance in vivo. An analysis of haplotypes flanking K13 suggested the presence of multiple strains with the Cys580Tyr mutation rather than a single strain expanding across the three sites.
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37
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Amato R, Lim P, Miotto O, Amaratunga C, Dek D, Pearson RD, Almagro-Garcia J, Neal AT, Sreng S, Suon S, Drury E, Jyothi D, Stalker J, Kwiatkowski DP, Fairhurst RM. Genetic markers associated with dihydroartemisinin-piperaquine failure in Plasmodium falciparum malaria in Cambodia: a genotype-phenotype association study. THE LANCET. INFECTIOUS DISEASES 2017; 17:164-173. [PMID: 27818095 PMCID: PMC5564489 DOI: 10.1016/s1473-3099(16)30409-1] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND As the prevalence of artemisinin-resistant Plasmodium falciparum malaria increases in the Greater Mekong subregion, emerging resistance to partner drugs in artemisinin combination therapies seriously threatens global efforts to treat and eliminate this disease. Molecular markers that predict failure of artemisinin combination therapy are urgently needed to monitor the spread of partner drug resistance, and to recommend alternative treatments in southeast Asia and beyond. METHODS We did a genome-wide association study of 297 P falciparum isolates from Cambodia to investigate the relationship of 11 630 exonic single-nucleotide polymorphisms (SNPs) and 43 copy number variations (CNVs) with in-vitro piperaquine 50% inhibitory concentrations (IC50s), and tested whether these genetic variants are markers of treatment failure with dihydroartemisinin-piperaquine. We then did a survival analysis of 133 patients to determine whether candidate molecular markers predicted parasite recrudescence following dihydroartemisinin-piperaquine treatment. FINDINGS Piperaquine IC50s increased significantly from 2011 to 2013 in three Cambodian provinces (2011 vs 2013 median IC50s: 20·0 nmol/L [IQR 13·7-29·0] vs 39·2 nmol/L [32·8-48·1] for Ratanakiri, 19·3 nmol/L [15·1-26·2] vs 66·2 nmol/L [49·9-83·0] for Preah Vihear, and 19·6 nmol/L [11·9-33·9] vs 81·1 nmol/L [61·3-113·1] for Pursat; all p≤10-3; Kruskal-Wallis test). Genome-wide analysis of SNPs identified a chromosome 13 region that associates with raised piperaquine IC50s. A non-synonymous SNP (encoding a Glu415Gly substitution) in this region, within a gene encoding an exonuclease, associates with parasite recrudescence following dihydroartemisinin-piperaquine treatment. Genome-wide analysis of CNVs revealed that a single copy of the mdr1 gene on chromosome 5 and a novel amplification of the plasmepsin 2 and plasmepsin 3 genes on chromosome 14 also associate with raised piperaquine IC50s. After adjusting for covariates, both exo-E415G and plasmepsin 2-3 markers significantly associate (p=3·0 × 10-8 and p=1·7 × 10-7, respectively) with decreased treatment efficacy (survival rates 0·38 [95% CI 0·25-0·51] and 0·41 [0·28-0·53], respectively). INTERPRETATION The exo-E415G SNP and plasmepsin 2-3 amplification are markers of piperaquine resistance and dihydroartemisinin-piperaquine failures in Cambodia, and can help monitor the spread of these phenotypes into other countries of the Greater Mekong subregion, and elucidate the mechanism of piperaquine resistance. Since plasmepsins are involved in the parasite's haemoglobin-to-haemozoin conversion pathway, targeted by related antimalarials, plasmepsin 2-3 amplification probably mediates piperaquine resistance. FUNDING Intramural Research Program of the US National Institute of Allergy and Infectious Diseases, National Institutes of Health, Wellcome Trust, Bill & Melinda Gates Foundation, Medical Research Council, and UK Department for International Development.
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Affiliation(s)
- Roberto Amato
- Wellcome Trust Sanger Institute, Hinxton, UK; Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, Oxford, UK.
| | - Pharath Lim
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA; National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Olivo Miotto
- Wellcome Trust Sanger Institute, Hinxton, UK; Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Chanaki Amaratunga
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Dalin Dek
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Richard D Pearson
- Wellcome Trust Sanger Institute, Hinxton, UK; Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Jacob Almagro-Garcia
- Wellcome Trust Sanger Institute, Hinxton, UK; Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Aaron T Neal
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Sokunthea Sreng
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | | | | | - Jim Stalker
- Wellcome Trust Sanger Institute, Hinxton, UK
| | - Dominic P Kwiatkowski
- Wellcome Trust Sanger Institute, Hinxton, UK; Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Rick M Fairhurst
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA.
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38
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Srimuang K, Miotto O, Lim P, Fairhurst RM, Kwiatkowski DP, Woodrow CJ, Imwong M. Analysis of anti-malarial resistance markers in pfmdr1 and pfcrt across Southeast Asia in the Tracking Resistance to Artemisinin Collaboration. Malar J 2016; 15:541. [PMID: 27825353 PMCID: PMC5101715 DOI: 10.1186/s12936-016-1598-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/31/2016] [Indexed: 01/07/2023] Open
Abstract
Background Declining anti-malarial efficacy of artemisinin-based combination therapy, and reduced Plasmodium falciparum susceptibility to individual anti-malarials are being documented across an expanding area of Southeast Asia (SEA). Genotypic markers complement phenotypic studies in assessing the efficacy of individual anti-malarials. Methods The markers pfmdr1 and pfcrt were genotyped in parasite samples obtained in 2011–2014 at 14 TRAC (Tracking Resistance to Artemisinin Collaboration) sites in mainland Southeast Asia using a combination of PCR and next-generation sequencing methods. Results Pfmdr1 amplification, a marker of mefloquine and lumefantrine resistance, was highly prevalent at Mae Sot on the Thailand–Myanmar border (59.8% of isolates) and common (more than 10%) at sites in central Myanmar, eastern Thailand and western Cambodia; however, its prevalence was lower than previously documented in Pailin, western Cambodia. The pfmdr1 Y184F mutation was common, particularly in and around Cambodia, and the F1226Y mutation was found in about half of samples in Mae Sot. The functional significance of these two mutations remains unclear. Other previously documented pfmdr1 mutations were absent or very rare in the region. The pfcrt mutation K76T associated with chloroquine resistance was found in 98.2% of isolates. The CVIET haplotype made up 95% or more of isolates in western SEA while the CVIDT haplotype was common (30–40% of isolates) in north and northeastern Cambodia, southern Laos, and southern Vietnam. Conclusions These findings generate cause for concern regarding the mid-term efficacy of artemether–lumefantrine in Myanmar, while the absence of resistance-conferring pfmdr1 mutations and SVMNT pfcrt haplotypes suggests that amodiaquine could be an efficacious component of anti-malarial regimens in SEA. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1598-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Krongkan Srimuang
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Olivo Miotto
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Wellcome Trust Sanger Institute, Hinxton, UK.,Medical Research Council (MRC) Centre for Genomics and Global Health, University of Oxford, Oxford, UK
| | - Pharath Lim
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, 20852, USA
| | - Rick M Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, 20852, USA
| | - Dominic P Kwiatkowski
- Wellcome Trust Sanger Institute, Hinxton, UK.,Medical Research Council (MRC) Centre for Genomics and Global Health, University of Oxford, Oxford, UK
| | - Charles J Woodrow
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
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Chaorattanakawee S, Lon C, Jongsakul K, Gawee J, Sok S, Sundrakes S, Kong N, Thamnurak C, Chann S, Chattrakarn S, Praditpol C, Buathong N, Uthaimongkol N, Smith P, Sirisopana N, Huy R, Prom S, Fukuda MM, Bethell D, Walsh DS, Lanteri C, Saunders D. Ex vivo piperaquine resistance developed rapidly in Plasmodium falciparum isolates in northern Cambodia compared to Thailand. Malar J 2016; 15:519. [PMID: 27769299 PMCID: PMC5075182 DOI: 10.1186/s12936-016-1569-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background The recent dramatic decline in dihydroartemisinin-piperaquine (DHA-PPQ) efficacy in northwestern Cambodia has raised concerns about the rapid spread of piperaquine resistance just as DHA-PPQ is being introduced as first-line therapy in neighbouring countries. Methods Ex vivo parasite susceptibilities were tracked to determine the rate of progression of DHA, PPQ and mefloquine (MQ) resistance from sentinel sites on the Thai–Cambodian and Thai–Myanmar borders from 2010 to 2015. Immediate ex vivo (IEV) histidine-rich protein 2 (HRP-2) assays were used on fresh patient Plasmodium falciparum isolates to determine drug susceptibility profiles. Results IEV HRP-2 assays detected the precipitous emergence of PPQ resistance in Cambodia beginning in 2013 when 40 % of isolates had an IC90 greater than the upper limit of prior years, and this rate doubled to 80 % by 2015. In contrast, Thai–Myanmar isolates from 2013 to 14 remained PPQ-sensitive, while northeastern Thai isolates appeared to have an intermediate resistance profile. The opposite trend was observed for MQ where Cambodian isolates appeared to have a modest increase in overall sensitivity during the same period, with IC50 declining to median levels comparable to those found in Thailand. A significant association between increased PPQ IC50 and IC90 among Cambodian isolates with DHA-PPQ treatment failure was observed. Nearly all Cambodian and Thai isolates were deemed artemisinin resistant with a >1 % survival rate for DHA in the ring-stage assay (RSA), though there was no correlation among isolates to indicate cross-resistance between PPQ and artemisinins. Conclusions Clinical DHA-PPQ failures appear to be associated with declines in the long-acting partner drug PPQ, though sensitivity appears to remain largely intact for now in western Thailand. Rapid progression of PPQ resistance associated with DHA-PPQ treatment failures in northern Cambodia limits drugs of choice in this region, and urgently requires alternative therapy. The temporary re-introduction of artesunate AS-MQ is the current response to PPQ resistance in this area, due to inverse MQ and PPQ resistance patterns. This will require careful monitoring for re-emergence of MQ resistance, and possible simultaneous resistance to all three drugs (AS, MQ and PPQ). Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1569-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Suwanna Chaorattanakawee
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand.,Department of Parasitology and Entomology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Chanthap Lon
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand. .,USAMC-AFRIMS, Phnom Penh, Cambodia.
| | - Krisada Jongsakul
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | | | - Somethy Sok
- Royal Cambodian Armed Forces, Phnom Penh, Cambodia
| | - Siratchana Sundrakes
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Nareth Kong
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Chatchadaporn Thamnurak
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | | | - Sorayut Chattrakarn
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Chantida Praditpol
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Nillawan Buathong
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Nichapat Uthaimongkol
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Philip Smith
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | | | - Rekol Huy
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | - Mark M Fukuda
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Delia Bethell
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Douglas S Walsh
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
| | - Charlotte Lanteri
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand.,Department of Pathology and Area Laboratory Services, Microbiology Section, Brooke Army Medical Center, San Antonio, TX, USA
| | - David Saunders
- US Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Bangkok, Thailand
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40
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Barber BE, Grigg MJ, William T, Yeo TW, Anstey NM. The Treatment of Plasmodium knowlesi Malaria. Trends Parasitol 2016; 33:242-253. [PMID: 27707609 DOI: 10.1016/j.pt.2016.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/31/2016] [Accepted: 09/07/2016] [Indexed: 12/30/2022]
Abstract
Plasmodium knowlesi occurs across Southeast Asia and is the most common cause of malaria in Malaysia. High parasitaemias can develop rapidly, and the risk of severe disease in adults is at least as high as in falciparum malaria. Prompt initiation of effective treatment is therefore essential. Intravenous artesunate is highly effective in severe knowlesi malaria and in those with moderately high parasitaemia but otherwise uncomplicated disease. Both chloroquine and artemisinin-combination therapy (ACT) are highly effective for uncomplicated knowlesi malaria, with faster parasite clearance times and lower anaemia rates with ACT. Given the difficulties with microscope diagnosis of P. knowlesi, a unified treatment strategy of ACT for all Plasmodium species is recommended in coendemic regions.
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Affiliation(s)
- Bridget E Barber
- Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina 0810, Northern Territory, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu 88586, Sabah, Malaysia
| | - Matthew J Grigg
- Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina 0810, Northern Territory, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu 88586, Sabah, Malaysia
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu 88586, Sabah, Malaysia; Queen Elizabeth Hospital Clinical Research Centre, Kota Kinabalu 88586, Sabah, Malaysia; Jesselton Medical Centre, Kota Kinabalu 88300, Sabah, Malaysia
| | - Tsin W Yeo
- Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina 0810, Northern Territory, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu 88586, Sabah, Malaysia; Lee Kong Chian School of Medicine, Nanyang Technological University, 639798 Singapore; Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 308433 Singapore
| | - Nicholas M Anstey
- Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina 0810, Northern Territory, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu 88586, Sabah, Malaysia.
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41
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King AJ, Brown GD, Gilday AD, Forestier E, Larson TR, Graham IA. A Cytochrome P450-Mediated Intramolecular Carbon-Carbon Ring Closure in the Biosynthesis of Multidrug-Resistance-Reversing Lathyrane Diterpenoids. Chembiochem 2016; 17:1593-7. [PMID: 27272333 PMCID: PMC5095812 DOI: 10.1002/cbic.201600316] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Indexed: 11/24/2022]
Abstract
The Euphorbiaceae produce a wide variety of bioactive diterpenoids. These include the lathyranes, which have received much interest due to their ability to inhibit the ABC transporters responsible for the loss of efficacy of many chemotherapy drugs. The lathyranes are also intermediates in the biosynthesis of range of other bioactive diterpenoids with potential applications in the treatment of pain, HIV and cancer. We report here a gene cluster from Jatropha curcas that contains the genes required to convert geranylgeranyl pyrophosphate into a number of diterpenoids, including the lathyranes jolkinol C and epi-jolkinol C. The conversion of casbene to the lathyranes involves an intramolecular carbon-carbon ring closure. This requires the activity of two cytochrome P450s that we propose form a 6-hydroxy-5,9-diketocasbene intermediate, which then undergoes an aldol reaction. The discovery of the P450 genes required to convert casbene to lathyranes will allow the scalable heterologous production of these potential anticancer drugs, which can often only be sourced in limited quantities from their native plant.
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Affiliation(s)
- Andrew J King
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York, YO10 5DD, UK.
| | - Geoffrey D Brown
- Department of Chemistry, University of Reading, Whiteknights, Reading, RG6 6AD, UK
| | - Alison D Gilday
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York, YO10 5DD, UK
| | - Edith Forestier
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York, YO10 5DD, UK
| | - Tony R Larson
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York, YO10 5DD, UK
| | - Ian A Graham
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York, YO10 5DD, UK.
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Falq G, Van Den Bergh R, De Smet M, Etienne W, Nguon C, Rekol H, Imwong M, Dondorp A, Kindermans JM. Assessing the asymptomatic reservoir and dihydroartemisinin-piperaquine effectiveness in a low transmission setting threatened by artemisinin resistant Plasmodium falciparum. Malar J 2016; 15:446. [PMID: 27585957 PMCID: PMC5009552 DOI: 10.1186/s12936-016-1487-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background In Cambodia, elimination of artemisinin resistance through direct elimination of the Plasmodium falciparum parasite may be the only strategy. Prevalence and incidence at district and village levels were assessed in Chey Saen district, Preah Vihear province, North of Cambodia. Molecular and clinical indicators for artemisinin resistance were documented. Methods A cross sectional prevalence survey was conducted at village level in the district of Chey Saen from September to October 2014. Plasmodium spp. was assessed with high volume quantitative real-time polymerase chain reaction (qPCR). Plasmodium falciparum-positive samples were screened for mutations in the k13-propeller domain gene. Treatment effectiveness was established after 28 days (D28) using the same qPCR technique. Data from the provincial surveillance system targeting symptomatic cases, supported by Médecins Sans Frontières (MSF), were used to assess incidence. Results District P. falciparum prevalence was of 0.74 % [0.41; 1.21]; village prevalence ranged from 0 to 4.6 % [1.4; 10.5]. The annual incidence of P. falciparum was 16.8 cases per 1000 inhabitants in the district; village incidence ranged from 1.3 to 54.9 for 1000 inhabitants. Two geographical clusters with high number of cases were identified by both approaches. The marker for artemisinin resistance was found in six samples out of the 11 tested (55 %). 34.9 % of qPCR blood analysis of symptomatic patients were still positive at D28. Conclusions The overall low prevalence of P. falciparum was confirmed in Chey Saen district in Cambodia, while there were important variations between villages. Symptomatic cases had a different pattern and were likely acquired outside the villages. It illustrates the importance of prevalence surveys in targeting interventions for elimination. Mutations in the k13-propeller domain gene (C580Y), conferring artemisinin resistance, were highly prevalent in both symptomatic and asymptomatic cases (realizing the absolute figures remain low). Asymptomatic individuals could be an additional reservoir for artemisinin resistance. The low effectiveness of dihydroartemisinin–piperaquine (DHA–PPQ) for symptomatic cases indicates that PPQ is no longer able to complement the reduced potency of DHA to treat falciparum malaria and highlights the need for an alternative first-line treatment.
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Affiliation(s)
- Grégoire Falq
- Médecins Sans Frontières, 46, rue de l'Arbre Bénit, 1050, Brussels, Belgium
| | - Rafael Van Den Bergh
- Médecins Sans Frontières, 68, rue de Gasperich, 1617, Luxembourg City, Luxembourg
| | - Martin De Smet
- Médecins Sans Frontières, 46, rue de l'Arbre Bénit, 1050, Brussels, Belgium
| | - William Etienne
- Médecins Sans Frontières, 46, rue de l'Arbre Bénit, 1050, Brussels, Belgium
| | - Chea Nguon
- Centre for Parasitology, Entomology and Malaria Control, 477 Betong Street, Village Trapangsvay, Sanakat Phnom Penh Thmey, Khan Sen Sok, Phnom Penh, Cambodia
| | - Huy Rekol
- Centre for Parasitology, Entomology and Malaria Control, 477 Betong Street, Village Trapangsvay, Sanakat Phnom Penh Thmey, Khan Sen Sok, Phnom Penh, Cambodia
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Arjen Dondorp
- Mahidol Oxford Tropical Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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43
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Efficacy and Safety of Pyronaridine-Artesunate for Treatment of Uncomplicated Plasmodium falciparum Malaria in Western Cambodia. Antimicrob Agents Chemother 2016; 60:3884-90. [PMID: 26926629 DOI: 10.1128/aac.00039-16] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/25/2016] [Indexed: 01/28/2023] Open
Abstract
Pyronaridine-artesunate efficacy for the treatment of uncomplicated Plasmodium falciparum malaria was assessed in an area of artemisinin resistance in western Cambodia. This nonrandomized, single-arm, observational study was conducted between 2014 and 2015. Eligible patients were adults or children with microscopically confirmed P. falciparum infection and fever. Patients received pyronaridine-artesunate once daily for 3 days, dosed according to body weight. The primary outcome was an adequate clinical and parasitological response (ACPR) on day 42, estimated by using Kaplan-Meier analysis, PCR adjusted to exclude reinfection. One hundred twenty-three patients were enrolled. Day 42 PCR-crude ACPRs were 87.2% (95% confidence interval [CI], 79.7 to 92.6%) for the overall study, 89.8% (95% CI, 78.8 to 95.3%) for Pursat, and 82.1% (95% CI, 68.4 to 90.2%) for Pailin. Day 42 PCR-adjusted ACPRs were 87.9% (95% CI, 80.6 to 93.2%) for the overall study, 89.8% (95% CI, 78.8 to 95.3%) for Pursat, and 84.0% (95% CI, 70.6 to 91.7%) for Pailin (P = 0.353 by a log rank test). Day 28 PCR-crude and -adjusted ACPRs were 93.2% (95% CI, 82.9 to 97.4%) and 88.1% (95% CI, 75.3 to 94.5%) for Pursat and Pailin, respectively. A significantly lower proportion of patients achieved day 3 parasite clearance in Pailin (56.4% [95% CI, 43.9 to 69.6%]) than in Pursat (86.7% [95% CI, 76.8 to 93.8%]; P = 0.0019). Fever clearance was also extended at Pailin versus Pursat (P < 0.0001). Most patients (95.9% [116/121]) harbored P. falciparum kelch13 C580Y mutant parasites. Pyronaridine-artesunate was well tolerated; mild increases in hepatic transaminase levels were consistent with data from previous reports. Pyronaridine-artesunate efficacy was below the World Health Organization-recommended threshold at day 42 for medicines with a long half-life (90%) for first-line treatment of P. falciparum malaria in western Cambodia despite high efficacy elsewhere in Asia and Africa. (This study has been registered at ClinicalTrials.gov under registration number NCT02389439.).
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Phyo AP, Ashley EA, Anderson TJC, Bozdech Z, Carrara VI, Sriprawat K, Nair S, White MM, Dziekan J, Ling C, Proux S, Konghahong K, Jeeyapant A, Woodrow CJ, Imwong M, McGready R, Lwin KM, Day NPJ, White NJ, Nosten F. Declining Efficacy of Artemisinin Combination Therapy Against P. Falciparum Malaria on the Thai-Myanmar Border (2003-2013): The Role of Parasite Genetic Factors. Clin Infect Dis 2016; 63:784-791. [PMID: 27313266 PMCID: PMC4996140 DOI: 10.1093/cid/ciw388] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/05/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Deployment of mefloquine-artesunate (MAS3) on the Thailand-Myanmar border has led to a sustained reduction in falciparum malaria, although antimalarial efficacy has declined substantially in recent years. The role of Plasmodium falciparum K13 mutations (a marker of artemisinin resistance) in reducing treatment efficacy remains controversial. METHODS Between 2003 and 2013, we studied the efficacy of MAS3 in 1005 patients with uncomplicated P. falciparum malaria in relation to molecular markers of resistance. RESULTS Polymerase chain reaction (PCR)-adjusted cure rates declined from 100% in 2003 to 81.1% in 2013 as the proportions of isolates with multiple Pfmdr1 copies doubled from 32.4% to 64.7% and those with K13 mutations increased from 6.7% to 83.4%. K13 mutations conferring moderate artemisinin resistance (notably E252Q) predominated initially but were later overtaken by propeller mutations associated with slower parasite clearance (notably C580Y). Those infected with both multiple Pfmdr1 copy number and a K13 propeller mutation were 14 times more likely to fail treatment. The PCR-adjusted cure rate was 57.8% (95% confidence interval [CI], 45.4, 68.3) compared with 97.8% (95% CI, 93.3, 99.3) in patients with K13 wild type and Pfmdr1 single copy. K13 propeller mutation alone was a strong risk factor for recrudescence (P = .009). The combined population attributable fraction of recrudescence associated with K13 mutation and Pfmdr1 amplification was 82%. CONCLUSIONS The increasing prevalence of K13 mutations was the decisive factor for the recent and rapid decline in efficacy of artemisinin-based combination (MAS3) on the Thailand-Myanmar border.
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Affiliation(s)
- Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Elizabeth A Ashley
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tim J C Anderson
- Department of Genetics, Texas Biomedical Research Institute, San Antonio; and
| | - Zbynek Bozdech
- Division of Molecular Genetics & Cell Biology, School of Biological Sciences, Nanyang Technological University, Singapore
| | - Verena I Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kanlaya Sriprawat
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Shalini Nair
- Department of Genetics, Texas Biomedical Research Institute, San Antonio; and
| | - Marina McDew White
- Department of Genetics, Texas Biomedical Research Institute, San Antonio; and
| | - Jerzy Dziekan
- Division of Molecular Genetics & Cell Biology, School of Biological Sciences, Nanyang Technological University, Singapore
| | - Clare Ling
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Kamonchanok Konghahong
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Atthanee Jeeyapant
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
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45
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Dwivedi A, Khim N, Reynes C, Ravel P, Ma L, Tichit M, Bourchier C, Kim S, Dourng D, Khean C, Chim P, Siv S, Frutos R, Lek D, Mercereau-Puijalon O, Ariey F, Menard D, Cornillot E. Plasmodium falciparum parasite population structure and gene flow associated to anti-malarial drugs resistance in Cambodia. Malar J 2016; 15:319. [PMID: 27301553 PMCID: PMC4908689 DOI: 10.1186/s12936-016-1370-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/02/2016] [Indexed: 11/25/2022] Open
Abstract
Background Western Cambodia is recognized as the epicentre of emergence of Plasmodium falciparum multi-drug resistance. The emergence of artemisinin resistance has been observed in this area since 2008–2009 and molecular signatures associated to artemisinin resistance have been characterized in k13 gene. At present, one of the major threats faced, is the possible spread of Asian artemisinin resistant parasites over the world threatening millions of people and jeopardizing malaria elimination programme efforts. To anticipate the diffusion of artemisinin resistance, the identification of the P. falciparum population structure and the gene flow among the parasite population in Cambodia are essential. Methods To this end, a mid-throughput PCR-LDR-FMA approach based on LUMINEX technology was developed to screen for genetic barcode in 533 blood samples collected in 2010–2011 from 16 health centres in malaria endemics areas in Cambodia. Results Based on successful typing of 282 samples, subpopulations were characterized along the borders of the country. Each 11-loci barcode provides evidence supporting allele distribution gradient related to subpopulations and gene flow. The 11-loci barcode successfully identifies recently emerging parasite subpopulations in western Cambodia that are associated with the C580Y dominant allele for artemisinin resistance in k13 gene. A subpopulation was identified in northern Cambodia that was associated to artemisinin (R539T resistant allele of k13 gene) and mefloquine resistance. Conclusions The gene flow between these subpopulations might have driven the spread of artemisinin resistance over Cambodia. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1370-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ankit Dwivedi
- Institut de Biologie Computationnelle (IBC), Montpellier, France.,IRCM-INSERM U1194, Institut de Recherche en Cancérologie de Montpellier, Montpellier, France.,Université de Montpellier, Montpellier, France.,ICM, Institut régional du Cancer Montpellier, Montpellier, France
| | - Nimol Khim
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Christelle Reynes
- Laboratoire de Biostatistiques, Informatique et Physique Pharmaceutique, UFR Pharmacie, Université de Montpellier, Montpellier, France.,Institut de Génomique Fonctionnelle, Montpellier, France
| | - Patrice Ravel
- IRCM-INSERM U1194, Institut de Recherche en Cancérologie de Montpellier, Montpellier, France.,Université de Montpellier, Montpellier, France.,ICM, Institut régional du Cancer Montpellier, Montpellier, France
| | - Laurence Ma
- Genopole Sequencing Platform, Institut Pasteur, Paris, France
| | - Magali Tichit
- Genopole Sequencing Platform, Institut Pasteur, Paris, France
| | | | - Saorin Kim
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Dany Dourng
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Chanra Khean
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Pheaktra Chim
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Sovannaroth Siv
- National Centre for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Roger Frutos
- UMR 17, Intertryp, Cirad-IRD, Campus International de Baillarguet, Montpellier, France.,IES-UMR 5214, Institut d'Electronique et des Systèmes, Université de Montpellier-CNRS, Montpellier, France
| | - Dysoley Lek
- National Centre for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | | | - Frédéric Ariey
- Parasite Molecular Immunology Unit, Institut Pasteur, Paris, France
| | - Didier Menard
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia.
| | - Emmanuel Cornillot
- Institut de Biologie Computationnelle (IBC), Montpellier, France. .,IRCM-INSERM U1194, Institut de Recherche en Cancérologie de Montpellier, Montpellier, France. .,Université de Montpellier, Montpellier, France. .,ICM, Institut régional du Cancer Montpellier, Montpellier, France.
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46
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Fairhurst RM, Dondorp AM. Artemisinin-Resistant Plasmodium falciparum Malaria. Microbiol Spectr 2016; 4:10.1128/microbiolspec.EI10-0013-2016. [PMID: 27337450 PMCID: PMC4992992 DOI: 10.1128/microbiolspec.ei10-0013-2016] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Indexed: 01/05/2023] Open
Abstract
For more than five decades, Southeast Asia (SEA) has been fertile ground for the emergence of drug-resistant Plasmodium falciparum malaria. After generating parasites resistant to chloroquine, sulfadoxine, pyrimethamine, quinine, and mefloquine, this region has now spawned parasites resistant to artemisinins, the world's most potent antimalarial drugs. In areas where artemisinin resistance is prevalent, artemisinin combination therapies (ACTs)-the first-line treatments for malaria-are failing fast. This worrisome development threatens to make malaria practically untreatable in SEA, and threatens to compromise global endeavors to eliminate this disease. A recent series of clinical, in vitro, genomics, and transcriptomics studies in SEA have defined in vivo and in vitro phenotypes of artemisinin resistance, identified its causal genetic determinant, explored its molecular mechanism, and assessed its clinical impact. Specifically, these studies have established that artemisinin resistance manifests as slow parasite clearance in patients and increased survival of early-ring-stage parasites in vitro; is caused by single nucleotide polymorphisms in the parasite's K13 gene, is associated with an upregulated "unfolded protein response" pathway that may antagonize the pro-oxidant activity of artemisinins, and selects for partner drug resistance that rapidly leads to ACT failures. In SEA, clinical studies are urgently needed to monitor ACT efficacy where K13 mutations are prevalent, test whether new combinations of currently available drugs cure ACT failures, and advance new antimalarial compounds through preclinical pipelines and into clinical trials. Intensifying these efforts should help to forestall the spread of artemisinin and partner drug resistance from SEA to sub-Saharan Africa, where the world's malaria transmission, morbidity, and mortality rates are highest.
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Affiliation(s)
- Rick M. Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland 20852, United States of America
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, United Kingdom
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47
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Abstract
For more than five decades, Southeast Asia (SEA) has been fertile ground for the emergence of drug-resistant Plasmodium falciparum malaria. After generating parasites resistant to chloroquine, sulfadoxine, pyrimethamine, quinine, and mefloquine, this region has now spawned parasites resistant to artemisinins, the world's most potent antimalarial drugs. In areas where artemisinin resistance is prevalent, artemisinin combination therapies (ACTs)-the first-line treatments for malaria-are failing fast. This worrisome development threatens to make malaria practically untreatable in SEA, and threatens to compromise global endeavors to eliminate this disease. A recent series of clinical, in vitro, genomics, and transcriptomics studies in SEA have defined in vivo and in vitro phenotypes of artemisinin resistance, identified its causal genetic determinant, explored its molecular mechanism, and assessed its clinical impact. Specifically, these studies have established that artemisinin resistance manifests as slow parasite clearance in patients and increased survival of early-ring-stage parasites in vitro; is caused by single nucleotide polymorphisms in the parasite's K13 gene, is associated with an upregulated "unfolded protein response" pathway that may antagonize the pro-oxidant activity of artemisinins, and selects for partner drug resistance that rapidly leads to ACT failures. In SEA, clinical studies are urgently needed to monitor ACT efficacy where K13 mutations are prevalent, test whether new combinations of currently available drugs cure ACT failures, and advance new antimalarial compounds through preclinical pipelines and into clinical trials. Intensifying these efforts should help to forestall the spread of artemisinin and partner drug resistance from SEA to sub-Saharan Africa, where the world's malaria transmission, morbidity, and mortality rates are highest.
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48
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Tun KM, Jeeyapant A, Imwong M, Thein M, Aung SSM, Hlaing TM, Yuentrakul P, Promnarate C, Dhorda M, Woodrow CJ, Dondorp AM, Ashley EA, Smithuis FM, White NJ, Day NPJ. Parasite clearance rates in Upper Myanmar indicate a distinctive artemisinin resistance phenotype: a therapeutic efficacy study. Malar J 2016; 15:185. [PMID: 27036739 PMCID: PMC4815199 DOI: 10.1186/s12936-016-1240-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/16/2016] [Indexed: 01/23/2023] Open
Abstract
Background Artemisinin resistance in Plasmodium falciparum extends across Southeast Asia where it is associated with worsening partner drug resistance and a decline in the efficacy of frontline artemisinin-based combination therapy. Dihydroartemisinin-piperaquine (DP) is an essential component of preventive and curative treatment in the region, but its therapeutic efficacy has fallen in Cambodia. Methods A prospective clinical and parasitological evaluation of DP was conducted at two sites in Upper Myanmar between August 2013 and December 2014, enrolling 116 patients with acute uncomplicated falciparum malaria. Patients received DP orally for 3 days together with primaquine 0.25 mg/kg on admission. Parasite clearance half-lives based on 6 hourly blood smears, and day 42 therapeutic responses were assessed as well as parasite K13 genotypes. Results Median parasite clearance half-life was prolonged, and clearance half-life was greater than 5 h in 21 % of patients. Delayed parasite clearance was significantly associated with mutations in the propeller region of the parasite k13 gene. The k13 F446I mutation was found in 25.4 % of infections and was associated with a median clearance half-life of 4.7 h compared with 2.7 h for infections without k13 mutations (p < 0.001). There were no failures after 42 days of follow-up, although 18 % of patients had persistent parasitaemia on day 3. Conclusion The dominant k13 mutation observed in Upper Myanmar, F446I, appears to be associated with an intermediate rate of parasite clearance compared to other common mutations described elsewhere in the Greater Mekong Subregion. Discerning this phenotype requires relatively detailed clearance measurements, highlighting the importance of methodology in assessing artemisinin resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1240-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kyaw Myo Tun
- Defence Services Medical Research Centre, Naypyitaw, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Atthanee Jeeyapant
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Min Thein
- Defence Services Medical Research Centre, Naypyitaw, Myanmar
| | | | | | - Prayoon Yuentrakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand
| | | | - Mehul Dhorda
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Worldwide Antimalarial Resistance Network (WWARN), Bangkok, Thailand
| | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand
| | - Frank M Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Medical Action Myanmar, Yangon, Myanmar
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Rd., Ratchathewi District, Bangkok, 10400, Thailand. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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49
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Tripura R, Peto TJ, Chalk J, Lee SJ, Sirithiranont P, Nguon C, Dhorda M, von Seidlein L, Maude RJ, Day NPJ, Imwong M, White NJ, Dondorp AM. Persistent Plasmodium falciparum and Plasmodium vivax infections in a western Cambodian population: implications for prevention, treatment and elimination strategies. Malar J 2016; 15:181. [PMID: 27013512 PMCID: PMC4806483 DOI: 10.1186/s12936-016-1224-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Subclinical Plasmodium parasitaemia is an important reservoir for the transmission and persistence of malaria, particularly in low transmission areas. Methods Using ultrasensitive quantitative PCR (uPCR) for the detection of parasitaemia, the entire population of three Cambodian villages in Pailin province were followed for 1 year at three-monthly intervals. A cohort of adult participants found initially to have asymptomatic malaria parasitaemia was followed monthly over the same period. Results The initial cross sectional survey in June 2013 (M0) of 1447 asymptomatic residents found that 32 (2.2 %) had Plasmodium falciparum, 48 (3.3 %) had P. vivax, 4 (0.3 %) had mixed infections and in 142/1447 (9.8 %) malaria was detected but there was insufficient DNA to identify the species (Plasmodium. species). Polymorphisms in the ‘K13-propeller’ associated with reduced susceptibility to artemisinin derivatives (C580Y) were found in 17/32 (51 %) P. falciparum strains. Monthly follow-up without treatment of 24 adult participants with asymptomatic mono or mixed P. falciparum infections found that 3/24 (13 %) remained parasitaemic for 2–4 months, whereas the remaining 21/24 (87 %) participants had cleared their parasitaemia after 1 month. In contrast, 12/34 (35 %) adult participants with P. vivax mono-infection at M0 had malaria parasites (P. vivax or P. sp.) during four or more of the following 11 monthly surveys. Conclusions This longitudinal survey in a low transmission setting shows limited duration of P. falciparum carriage, but prolonged carriage of P. vivax infections. Radical treatment of P. vivax infections by 8-aminoquinoline regimens may be required to eliminate all malaria from Cambodia. Trial registration ClinicalTrials.gov NCT01872702 Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1224-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rupam Tripura
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Thomas J Peto
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jeremy Chalk
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sue J Lee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Pasathorn Sirithiranont
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chea Nguon
- National Centre for Parasitology, Entomology, and Malaria Control (CNM), Trapeng Svay Village, Sangkat Phnom Penh Thmei, Khan Sen Sok, Phnom Penh, Cambodia
| | - Mehul Dhorda
- WorldWide Antimalarial Resistance Network, Asia Regional Centre, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lorenz von Seidlein
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW The emergence of artemisinin resistance in Southeast Asia (SEA), where artemisinin combination therapies (ACTs) are beginning to fail, threatens global endeavors to control and eliminate Plasmodium falciparum malaria. Future efforts to prevent the spread of this calamity to Africa will benefit from last year's tremendous progress in understanding artemisinin resistance. RECENT FINDINGS Multiple international collaborations have established that artemisinin resistance is associated with slow parasite clearance in patients, increased survival of early-ring-stage parasites in vitro, single-nucleotide polymorphisms (SNPs) in the parasite's kelch protein gene (K13), parasite 'founder' populations sharing a genetic background of four additional SNPs, parasite transcriptional profiles reflecting an 'unfolded protein response' and decelerated parasite development, and elevated parasite phosphatidylinositol-3-kinase activity. In Western Cambodia, where the K13 C580Y mutation is approaching fixation, the frontline ACT is failing to cure nearly half of patients, likely due to partner drug resistance. In Africa, where dozens of K13 mutations have been detected at low frequency, there is no evidence yet of artemisinin resistance. SUMMARY In SEA, clinical and epidemiological investigations are urgently needed to stop the further spread of artemisinin resistance, monitor the efficacy of ACTs where K13 mutations are prevalent, identify currently-available drug regimens that cure ACT failures, and rapidly advance new antimalarial compounds through preclinical studies and clinical trials.
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