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Molecular detection of antimalarial drug resistance in Plasmodium vivax from returned travellers to NSW, Australia during 2008-2018. Pathogens 2020; 9:pathogens9020101. [PMID: 32033493 PMCID: PMC7168284 DOI: 10.3390/pathogens9020101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
To monitor drug resistance in Plasmodium vivax, a multidrug resistance 1 (Pvmdr1) gene and a putative transporter protein (Pvcrt-o) gene were used as molecular markers for chloroquine resistance. The biomarkers, the dihydrofolate reductase (Pvdhfr) gene and the dihydropteroate synthetase (Pvdhps) gene, were also used for the detection of resistance to sulphadoxine-pyrimethamine (SP); this drug is often accidentally used to treat P. vivax infections. Clinical blood samples (n = 120) were collected from patients who had been to one of eight malaria-endemic countries and diagnosed with P. vivax infection. The chloroquine resistance marker, the Pvmdr1 gene, showed F976:L1076 mutations and L1076 mutation. A K10 insertion in the Pvcrt-o gene was also found among the samples successfully sequenced. A combination of L/I57:R58:M61:T117 mutations in the Pvdhfr gene and G383:G553 mutations in the Pvdhps gene were also observed. Mutations found in these genes indicate that drug resistance is present in these eight countries. Whether or not countries are using chloroquine to treat P. vivax, there appears to be an increase in mutation numbers in resistance gene markers. The detected changes in mutation rates of these genes do suggest that there is still a trend towards increasing P. vivax resistance to chloroquine. The presence of the mutations associated with SP resistance indicates that P. vivax has had exposure to SP and this may be a consequence of either misdiagnosis or coinfections with P. falciparum in the past.
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2
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Malaria Epidemiology at the Clone Level. Trends Parasitol 2017; 33:974-985. [PMID: 28966050 DOI: 10.1016/j.pt.2017.08.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/14/2017] [Accepted: 08/30/2017] [Indexed: 01/08/2023]
Abstract
Genotyping to distinguish between parasite clones is nowadays a standard in many molecular epidemiological studies of malaria. It has become crucial in drug trials and to follow individual clones in epidemiological studies, and to understand how drug resistance emerges and spreads. Here, we review the applications of the increasingly available genotyping tools and whole-genome sequencing data, and argue for a better integration of population genetics findings into malaria-control strategies.
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3
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Baird JK, Valecha N, Duparc S, White NJ, Price RN. Diagnosis and Treatment of Plasmodium vivax Malaria. Am J Trop Med Hyg 2016; 95:35-51. [PMID: 27708191 PMCID: PMC5198890 DOI: 10.4269/ajtmh.16-0171] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/19/2016] [Indexed: 11/07/2022] Open
Abstract
The diagnosis and treatment of Plasmodium vivax malaria differs from that of Plasmodium falciparum malaria in fundamentally important ways. This article reviews the guiding principles, practices, and evidence underpinning the diagnosis and treatment of P. vivax malaria.
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Affiliation(s)
- J Kevin Baird
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Neena Valecha
- National Institute for Malaria Research, New Delhi, India
| | | | - Nicholas J White
- Mahidol Oxford 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, United Kingdom
| | - Ric N Price
- Division of Global and Tropical Health, Menzies School of Health Research-Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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4
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Siqueira AM, Alencar AC, Melo GC, Magalhaes BL, Machado K, Alencar Filho AC, Kuehn A, Marques MM, Manso MC, Felger I, Vieira JLF, Lameyre V, Daniel-Ribeiro CT, Lacerda MVG. Fixed-Dose Artesunate-Amodiaquine Combination vs Chloroquine for Treatment of Uncomplicated Blood Stage P. vivax Infection in the Brazilian Amazon: An Open-Label Randomized, Controlled Trial. Clin Infect Dis 2016; 64:166-174. [PMID: 27988484 PMCID: PMC5215218 DOI: 10.1093/cid/ciw706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/18/2016] [Indexed: 01/31/2023] Open
Abstract
In the Brazilian Amazon, the artesunate–amodiaquine combination was more effective in preventing Plasmodium vivax recurrence. With a favorable safety profile, this antimalarial treatment proved to be a good first-line alternative. Chloroquine resistance is probably underestimated in the area. Background. Despite increasing evidence of the development of Plasmodium vivax chloroquine (CQ) resistance, there have been no trials comparing its efficacy with that of artemisinin-based combination therapies (ACTs) in Latin America. Methods. This randomized controlled trial compared the antischizontocidal efficacy and safety of a 3-day supervised treatment of the fixed-dose combination artesunate-amodiaquine Winthrop® (ASAQ) versus CQ for treatment of uncomplicated P. vivax infection in Manaus, Brazil. Patients were followed for 42 days. Primary endpoints were adequate clinical and parasitological responses (ACPR) rates at day 28. Genotype-adjustment was performed. Results. From 2012 to 2013, 380 patients were enrolled. In the per-protocol (PP) analysis, adjusted-ACPR was achieved in 100% (165/165) and 93.6% (161/172) of patients in the ASAQ and CQ arm (difference 6.4%, 95% CI 2.7%; 10.1%) at day 28 and in 97.4% (151/155) and 77.7% (129/166), respectively (difference 19.7%, 95% CI 12.9%; 26.5%), at day 42. Apart from ITT D28 assessment, superiority of ASAQ on ACPR was demonstrated. ASAQ presented faster clearance of parasitaemia and fever. Based on CQ blood level measurements, CQ resistance prevalence was estimated at 11.5% (95% CI: 7.5-17.3) up to day 42. At least one emergent adverse event (AE) was recorded for 79/190 (41x6%) in the ASAQ group and for 85/190 (44x7%) in the CQ group. Both treatments had similar safety profiles. Conclusions. ASAQ exhibited high efficacy against CQ resistant P. vivax and is an adequate alternative in the study area. Studies with an efficacious comparator, longer follow-up and genotype-adjustment can improve CQR characterization. Clinical Trials Registration. NCT01378286.
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Affiliation(s)
- Andre M Siqueira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, .,Universidade do Estado do Amazonas, Manaus.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro
| | - Aline C Alencar
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Gisely C Melo
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Belisa L Magalhaes
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Kim Machado
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado
| | | | - Andrea Kuehn
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | | | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | | | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus.,Instituto Leônidas e Maria Deane, Fundação Oswaldo Cruz, Manaus, Brazil
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5
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Barnadas C, Timinao L, Javati S, Iga J, Malau E, Koepfli C, Robinson LJ, Senn N, Kiniboro B, Rare L, Reeder JC, Siba PM, Zimmerman PA, Karunajeewa H, Davis TM, Mueller I. Significant geographical differences in prevalence of mutations associated with Plasmodium falciparum and Plasmodium vivax drug resistance in two regions from Papua New Guinea. Malar J 2015; 14:399. [PMID: 26452541 PMCID: PMC4600278 DOI: 10.1186/s12936-015-0879-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/31/2015] [Indexed: 12/22/2022] Open
Abstract
Background Drug resistance remains a major obstacle to malaria treatment and control. It can arise and spread rapidly, and vary substantially even at sub-national level. National malaria programmes require cost-effective and timely ways of characterizing drug-resistance at multiple sites within their countries. Methods An improved multiplexed post-PCR ligase detection reaction—fluorescent microsphere assay (LDR-FMA) was used to simultaneously determine the presence of mutations in chloroquine resistance transporter (crt), multidrug resistance 1 (mdr1), dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) genes in Plasmodium falciparum (n = 727) and Plasmodium vivax (n = 574) isolates collected in 2006 from cross-sectional community population surveys in two geographically distinct regions (Madang and East Sepik) of Papua New Guinea (PNG) where strong regional differences in in vivo aminoquinoline and antifolate therapeutic efficacy had previously been observed. Data were compared to those of a follow-up survey conducted in 2010. Results Despite some very low parasite densities, the assay successfully amplified all P. falciparum and P. vivax loci in 77 and 69 % of samples, respectively. In 2006, prevalences of pfdhfr (59R-108 N) double mutation/wild type pfdhps haplotype, pfcrt SVMNT haplotype (72S-76T double mutation), and 86Y pfmdr1 mutation all exceeded 90 %. For P. vivax, 65 % carried at least two pvdhfr mutations, 97 % the 647P pvdhps mutation and 54 % the 976F pvmdr1 mutation. Prevalence of mutant haplotypes was higher in Madang than East Sepik for pfcrt SVMNT (97.4 vs 83.3 %, p = 0.001), pfdhfr (59R-108 N) (100 vs 90.6 %, p = 0.001), pvdhfr haplotypes (75.8 vs 47.6 %, p = 0.001) and pvmdr1 976F (71.2 vs 26.2 %, p < 0.001). Data from a subsequent Madang survey in 2010 showed that the prevalence of pfdhps mutations increased significantly from <5 % to >30 % (p < 0.001) as did the prevalence of pvdhfr mutant haplotypes (from 75.8 to 97.4 %, p = 0.012). Conclusions This LDR-FMA multiplex platform shows feasibility for low-cost, high-throughput, rapid characterization of a broad range of drug-resistance markers in low parasitaemia infections. Significant geographical differences in mutation prevalence correlate with previous genotyping surveys and in vivo trials and may reflect variable drug pressure and differences in health-care access in these two PNG populations. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0879-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Céline Barnadas
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Lincoln Timinao
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Sarah Javati
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Jonah Iga
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Elisheba Malau
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Cristian Koepfli
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Leanne J Robinson
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Nicolas Senn
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Swiss Tropical and Public Health Institute, Basel, Switzerland.
| | - Benson Kiniboro
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Lawrence Rare
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | | | - Peter M Siba
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Peter A Zimmerman
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, USA.
| | - Harin Karunajeewa
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Timothy M Davis
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.
| | - Ivo Mueller
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia. .,Centre de Recerca en Salut Internacional de Barcelona, Barcelona, Spain.
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6
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Koepfli C, Rodrigues PT, Antao T, Orjuela-Sánchez P, Van den Eede P, Gamboa D, van Hong N, Bendezu J, Erhart A, Barnadas C, Ratsimbasoa A, Menard D, Severini C, Menegon M, Nour BYM, Karunaweera N, Mueller I, Ferreira MU, Felger I. Plasmodium vivax Diversity and Population Structure across Four Continents. PLoS Negl Trop Dis 2015; 9:e0003872. [PMID: 26125189 PMCID: PMC4488360 DOI: 10.1371/journal.pntd.0003872] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 06/02/2015] [Indexed: 01/12/2023] Open
Abstract
Plasmodium vivax is the geographically most widespread human malaria parasite. To analyze patterns of microsatellite diversity and population structure across countries of different transmission intensity, genotyping data from 11 microsatellite markers was either generated or compiled from 841 isolates from four continents collected in 1999–2008. Diversity was highest in South-East Asia (mean allelic richness 10.0–12.8), intermediate in the South Pacific (8.1–9.9) Madagascar and Sudan (7.9–8.4), and lowest in South America and Central Asia (5.5–7.2). A reduced panel of only 3 markers was sufficient to identify approx. 90% of all haplotypes in South Pacific, African and SE-Asian populations, but only 60–80% in Latin American populations, suggesting that typing of 2–6 markers, depending on the level of endemicity, is sufficient for epidemiological studies. Clustering analysis showed distinct clusters in Peru and Brazil, but little sub-structuring was observed within Africa, SE-Asia or the South Pacific. Isolates from Uzbekistan were exceptional, as a near-clonal parasite population was observed that was clearly separated from all other populations (FST>0.2). Outside Central Asia FST values were highest (0.11–0.16) between South American and all other populations, and lowest (0.04–0.07) between populations from South-East Asia and the South Pacific. These comparisons between P. vivax populations from four continents indicated that not only transmission intensity, but also geographical isolation affect diversity and population structure. However, the high effective population size results in slow changes of these parameters. This persistency must be taken into account when assessing the impact of control programs on the genetic structure of parasite populations. Plasmodium vivax is the predominant malaria parasite in Latin America, Asia and the South Pacific. Different factors are expected to shape diversity and population structure across continents, e.g. transmission intensity which is much lower in South America as compared to Southeast-Asia and the South Pacific, or geographical isolation of P. vivax populations in the South Pacific. We have compiled data from 841 isolates from South and Central America, Africa, Central Asia, Southeast-Asia and the South Pacific typed with a panel of 11 microsatellite markers. Diversity was highest in Southeast-Asia, where transmission is intermediate-high and migration of infected hosts is high, and lowest in South America and Central Asia where malaria transmission is low and focal. Reducing the panel of microsatellites showed that 2–6 markers are sufficient for genotyping for most drug trials and epidemiological studies, as these markers can identify >90% of all haplotypes. Parasites clustered according to continental origin, with high population differentiation between South American and Central Asian populations and the other populations, and lowest differences between Southeast-Asia and the South Pacific. Current attempts to reduce malaria transmission might change this pattern, but only after transmission is reduced for an extended period of time.
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Affiliation(s)
- Cristian Koepfli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Walter and Eliza Hall Institute, Parkville, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Priscila T. Rodrigues
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Tiago Antao
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Pamela Orjuela-Sánchez
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Peter Van den Eede
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dionicia Gamboa
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nguyen van Hong
- National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam
| | - Jorge Bendezu
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Annette Erhart
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Céline Barnadas
- Walter and Eliza Hall Institute, Parkville, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Arsène Ratsimbasoa
- Immunology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Didier Menard
- Institut Pasteur de Cambodge, Malaria Molecular Epidemiology Unit, Phnom Penh, Cambodia
| | - Carlo Severini
- Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Michela Menegon
- Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Bakri Y. M. Nour
- Department of Parasitology, Blue Nile National Institute for Communicable Diseases, University of Gezira, Wad Medani, Sudan
| | - Nadira Karunaweera
- Department of Parasitology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Barcelona Centre for International Health Research, Barcelona, Spain
| | - Marcelo U. Ferreira
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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7
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Laman M, Benjamin JM, Moore BR, Salib M, Tawat S, Davis WA, Siba PM, Robinson LJ, Davis TME. Artemether-lumefantrine versus artemisinin-naphthoquine in Papua New Guinean children with uncomplicated malaria: a six months post-treatment follow-up study. Malar J 2015; 14:121. [PMID: 25889150 PMCID: PMC4374335 DOI: 10.1186/s12936-015-0624-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In a recent trial of artemisinin-naphthoquine (artemisinin-NQ) and artemether-lumefantrine (AM-LM) therapy in young children from Papua New Guinea (PNG), there were no treatment failures in artemisinin-NQ-treated children with Plasmodium falciparum or Plasmodium vivax compared with 2.2% and 30.0%, respectively, in AM-LM-treated children during 42 days of follow-up. To determine whether, consistent with the long elimination half-life of NQ, this difference in efficacy would be more durable, clinical episodes of malaria were assessed in a subset of trial patients followed for six months post-treatment. METHODS For children completing trial procedures and who were assessable at six months, all within-trial and subsequent clinical malaria episodes were ascertained, the latter by clinic attendances and/or review of hand-held health records. Presentations with non-malarial illness were also recorded. Differences between allocated treatments for pre-specified endpoints were determined using Kaplan-Meier survival analysis. RESULTS Of 247 children who were followed to Day 42, 176 (71.3%) were included in the present sub-study, 87 allocated to AM-LM and 89 to artemisinin-NQ. Twenty children in the AM-LM group (32.8%) had a first episode of clinical malaria within six months compared with 10 (16.4%) in the artemisinin-NQ group (P = 0.033, log rank test). The median (interquartile range) time to first episode of clinical malaria was 64 (50-146) vs 116 (77-130) days, respectively (P = 0.20). There were no between-group differences in the incidence of first presentation with non-malarial illness (P = 0.31). CONCLUSIONS The greater effectiveness of artemisinin-NQ over conventional AM-LM extends to at least six months post-treatment for clinical malaria but not non-malarial illness. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12610000913077 .
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Affiliation(s)
- Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia. .,Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - John M Benjamin
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Brioni R Moore
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia. .,Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Somoyang Tawat
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Wendy A Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea. .,Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, VIC, Australia. .,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia.
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
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8
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Laman M, Moore BR, Benjamin JM, Yadi G, Bona C, Warrel J, Kattenberg JH, Koleala T, Manning L, Kasian B, Robinson LJ, Sambale N, Lorry L, Karl S, Davis WA, Rosanas-Urgell A, Mueller I, Siba PM, Betuela I, Davis TME. Artemisinin-naphthoquine versus artemether-lumefantrine for uncomplicated malaria in Papua New Guinean children: an open-label randomized trial. PLoS Med 2014; 11:e1001773. [PMID: 25549086 PMCID: PMC4280121 DOI: 10.1371/journal.pmed.1001773] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 11/18/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Artemisinin combination therapies (ACTs) with broad efficacy are needed where multiple Plasmodium species are transmitted, especially in children, who bear the brunt of infection in endemic areas. In Papua New Guinea (PNG), artemether-lumefantrine is the first-line treatment for uncomplicated malaria, but it has limited efficacy against P. vivax. Artemisinin-naphthoquine should have greater activity in vivax malaria because the elimination of naphthoquine is slower than that of lumefantrine. In this study, the efficacy, tolerability, and safety of these ACTs were assessed in PNG children aged 0.5-5 y. METHODS AND FINDINGS An open-label, randomized, parallel-group trial of artemether-lumefantrine (six doses over 3 d) and artemisinin-naphthoquine (three daily doses) was conducted between 28 March 2011 and 22 April 2013. Parasitologic outcomes were assessed without knowledge of treatment allocation. Primary endpoints were the 42-d P. falciparum PCR-corrected adequate clinical and parasitologic response (ACPR) and the P. vivax PCR-uncorrected 42-d ACPR. Non-inferiority and superiority designs were used for falciparum and vivax malaria, respectively. Because the artemisinin-naphthoquine regimen involved three doses rather than the manufacturer-specified single dose, the first 188 children underwent detailed safety monitoring. Of 2,542 febrile children screened, 267 were randomized, and 186 with falciparum and 47 with vivax malaria completed the 42-d follow-up. Both ACTs were safe and well tolerated. P. falciparum ACPRs were 97.8% and 100.0% in artemether-lumefantrine and artemisinin-naphthoquine-treated patients, respectively (difference 2.2% [95% CI -3.0% to 8.4%] versus -5.0% non-inferiority margin, p = 0.24), and P. vivax ACPRs were 30.0% and 100.0%, respectively (difference 70.0% [95% CI 40.9%-87.2%], p<0.001). Limitations included the exclusion of 11% of randomized patients with sub-threshold parasitemias on confirmatory microscopy and direct observation of only morning artemether-lumefantrine dosing. CONCLUSIONS Artemisinin-naphthoquine is non-inferior to artemether-lumefantrine in PNG children with falciparum malaria but has greater efficacy against vivax malaria, findings with implications in similar geo-epidemiologic settings within and beyond Oceania. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12610000913077. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Brioni R. Moore
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - John M. Benjamin
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Gumul Yadi
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Cathy Bona
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Jonathan Warrel
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Johanna H. Kattenberg
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Tamarah Koleala
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Bernadine Kasian
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Leanne J. Robinson
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Naomi Sambale
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Lina Lorry
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Stephan Karl
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Wendy A. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Anna Rosanas-Urgell
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Ivo Mueller
- Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
- Center de Recerca en Salut Internacional de Barcelona, Barcelona, Spain
| | - Peter M. Siba
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Inoni Betuela
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Timothy M. E. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- * E-mail:
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Global extent of chloroquine-resistant Plasmodium vivax: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2014; 14:982-91. [PMID: 25213732 PMCID: PMC4178238 DOI: 10.1016/s1473-3099(14)70855-2] [Citation(s) in RCA: 254] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Chloroquine is the first-line treatment for Plasmodium vivax malaria in most endemic countries, but resistance is increasing. Monitoring of antimalarial efficacy is essential, but in P. vivax infections the assessment of treatment efficacy is confounded by relapse from the dormant liver stages. We systematically reviewed P. vivax malaria treatment efficacy studies to establish the global extent of chloroquine resistance. METHODS We searched Medline, Web of Science, Embase, and the Cochrane Database of Systematic Reviews to identify studies published in English between Jan 1, 1960, and April 30, 2014, which investigated antimalarial treatment efficacy in P. vivax malaria. We excluded studies that did not include supervised schizonticidal treatment without primaquine. We determined rates of chloroquine resistance according to P. vivax malaria recurrence rates by day 28 whole-blood chloroquine concentrations at the time of recurrence and study enrolment criteria. FINDINGS We identified 129 eligible clinical trials involving 21,694 patients at 179 study sites and 26 case reports describing 54 patients. Chloroquine resistance was present in 58 (53%) of 113 assessable study sites, spread across most countries that are endemic for P. vivax. Clearance of parasitaemia assessed by microscopy in 95% of patients by day 2, or all patients by day 3, was 100% predictive of chloroquine sensitivity. INTERPRETATION Heterogeneity of study design and analysis has confounded global surveillance of chloroquine-resistant P. vivax, which is now present across most countries endemic for P. vivax. Improved methods for monitoring of drug resistance are needed to inform antimalarial policy in these regions. FUNDING Wellcome Trust (UK).
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Pharmacokinetic properties of single-dose primaquine in Papua New Guinean children: feasibility of abbreviated high-dose regimens for radical cure of vivax malaria. Antimicrob Agents Chemother 2013; 58:432-9. [PMID: 24189254 DOI: 10.1128/aac.01437-13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Since conventional 14-day primaquine (PMQ) radical cure of vivax malaria is associated with poor compliance, and as total dose, not therapy duration, determines efficacy, a preliminary pharmacokinetic study of two doses (0.5 and 1.0 mg/kg of body weight) was conducted in 28 healthy glucose-6-phosphate dehydrogenase-normal Papua New Guinean children, aged 5 to 12 years, to facilitate development of abbreviated high-dose regimens. Dosing was with food and was directly observed, and venous blood samples were drawn during a 168-h postdose period. Detailed safety monitoring was performed for hepatorenal function and hemoglobin and methemoglobin concentrations. Plasma concentrations of PMQ and its metabolite carboxyprimaquine (CPMQ) were determined by liquid chromatography-mass spectrometry and analyzed using population pharmacokinetic methods. The derived models were used in simulations. Both single-dose regimens were well tolerated with no changes in safety parameters. The mean PMQ central volume of distribution and clearance relative to bioavailability (200 liters/70 kg and 24.6 liters/h/70 kg) were within published ranges for adults. The median predicted maximal concentrations (Cmax) for both PMQ and CPMQ after the last dose of a 1.0 mg/kg 7-day PMQ regimen were approximately double those at the end of 14 days of 0.5 mg/kg daily, while a regimen of 1.0 mg/kg twice daily resulted in a 2.38 and 3.33 times higher Cmax for PMQ and CPMQ, respectively. All predicted median Cmax concentrations were within ranges for adult high-dose studies that also showed acceptable safety and tolerability. The present pharmacokinetic data, the first for PMQ in children, show that further studies of abbreviated high-dose regimens are feasible in this age group.
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Koepfli C, Colborn KL, Kiniboro B, Lin E, Speed TP, Siba PM, Felger I, Mueller I. A high force of plasmodium vivax blood-stage infection drives the rapid acquisition of immunity in papua new guinean children. PLoS Negl Trop Dis 2013; 7:e2403. [PMID: 24040428 PMCID: PMC3764149 DOI: 10.1371/journal.pntd.0002403] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 07/23/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND When both parasite species are co-endemic, Plasmodium vivax incidence peaks in younger children compared to P. falciparum. To identify differences in the number of blood stage infections of these species and its potential link to acquisition of immunity, we have estimated the molecular force of blood-stage infection of P. vivax ((mol)FOB, i.e. the number of genetically distinct blood-stage infections over time), and compared it to previously reported values for P. falciparum. METHODS P. vivax (mol)FOB was estimated by high resolution genotyping parasites in samples collected over 16 months in a cohort of 264 Papua New Guinean children living in an area highly endemic for P. falciparum and P. vivax. In this cohort, P. vivax episodes decreased three-fold over the age range of 1-4.5 years. RESULTS On average, children acquired 14.0 new P. vivax blood-stage clones/child/year-at-risk. While the incidence of clinical P. vivax illness was strongly associated with mol FOB (incidence rate ratio (IRR) = 1.99, 95% confidence interval (CI95) [1.80, 2.19]), (mol)FOB did not change with age. The incidence of P. vivax showed a faster decrease with age in children with high (IRR = 0.49, CI95 [0.38, 0.64] p<0.001) compared to those with low exposure (IRR = 0.63, CI95[0.43, 0.93] p = 0.02). CONCLUSION P. vivax (mol)FOB is considerably higher than P. falciparum (mol)FOB (5.5 clones/child/year-at-risk). The high number of P. vivax clones that infect children in early childhood contribute to the rapid acquisition of immunity against clinical P. vivax malaria.
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Affiliation(s)
- Cristian Koepfli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Kathryn L. Colborn
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
- University of California, Berkeley, Department of Biostatistics, Berkeley, California, United States of America
| | - Benson Kiniboro
- Papua New Guinea Institute of Medical Research, Goroka, Eastern Highland Province, Papua New Guinea
| | - Enmoore Lin
- Papua New Guinea Institute of Medical Research, Goroka, Eastern Highland Province, Papua New Guinea
| | | | - Peter M. Siba
- Papua New Guinea Institute of Medical Research, Goroka, Eastern Highland Province, Papua New Guinea
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
- Papua New Guinea Institute of Medical Research, Goroka, Eastern Highland Province, Papua New Guinea
- Barcelona Centre for International Health Research, Barcelona, Spain
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12
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Koepfli C, Timinao L, Antao T, Barry AE, Siba P, Mueller I, Felger I. A Large Plasmodium vivax Reservoir and Little Population Structure in the South Pacific. PLoS One 2013; 8:e66041. [PMID: 23823758 PMCID: PMC3688846 DOI: 10.1371/journal.pone.0066041] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 05/01/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction The importance of Plasmodium vivax in malaria elimination is increasingly being recognized, yet little is known about its population size and population genetic structure in the South Pacific, an area that is the focus of intensified malaria control. Methods We have genotyped 13 microsatellite markers in 295 P. vivax isolates from four geographically distinct sites in Papua New Guinea (PNG) and one site from Solomon Islands, representing different transmission intensities. Results Diversity was very high with expected heterozygosity values ranging from 0.62 to 0.98 for the different markers. Effective population size was high (12′872 to 19′533 per site). In PNG population structuring was limited with moderate levels of genetic differentiation. FST values (adjusted for high diversity of markers) were 0.14–0.15. Slightly higher levels were observed between PNG populations and Solomon Islands (FST = 0.16). Conclusions Low levels of population structure despite geographical barriers to transmission are in sharp contrast to results from regions of low P. vivax endemicity. Prior to intensification of malaria control programs in the study area, parasite diversity and effective population size remained high.
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Affiliation(s)
- Cristian Koepfli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Infection & Immunity Division, Walter & Eliza Hall Institute, Parkville, Victoria, Australia
| | - Lincoln Timinao
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- PNG Institute of Medical Research, Goroka, Papua New Guinea
| | - Tiago Antao
- Department of Biological Anthropology, University of Cambridge, Cambridge, United Kingdom
| | - Alyssa E. Barry
- Infection & Immunity Division, Walter & Eliza Hall Institute, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Peter Siba
- PNG Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Infection & Immunity Division, Walter & Eliza Hall Institute, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
- Barcelona Centre for International Health Research, Barcelona, Spain
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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13
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In vivo efficacy of artemether-lumefantrine and chloroquine against Plasmodium vivax: a randomized open label trial in central Ethiopia. PLoS One 2013; 8:e63433. [PMID: 23717423 PMCID: PMC3661577 DOI: 10.1371/journal.pone.0063433] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 04/02/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In vivo efficacy assessments of antimalarials are essential for ensuring effective case management. In Ethiopia, chloroquine (CQ) without primaquine is the first-line treatment for Plasmodium vivax in malarious areas, but artemether-lumefantrine (AL) is also commonly used. METHODS AND FINDINGS In 2009, we conducted a 42-day efficacy study of AL or CQ for P. vivax in Oromia Regional State, Ethiopia. Individuals with P. vivax monoinfection were enrolled. Primary endpoint was day 28 cure rate. In patients with recurrent parasitemia, drug level and genotyping using microsatellite markers were assessed. Using survival analysis, uncorrected patient cure rates at day 28 were 75.7% (95% confidence interval (CI) 66.8-82.5) for AL and 90.8% (95% CI 83.6-94.9) for CQ. During the 42 days of follow-up, 41.6% (47/113) of patients in the AL arm and 31.8% (34/107) in the CQ arm presented with recurrent P. vivax infection, with the median number of days to recurrence of 28 compared to 35 days in the AL and CQ arm, respectively. Using microsatellite markers to reclassify recurrent parasitemias with a different genotype as non-treatment failures, day 28 cure rates were genotype adjusted to 91.1% (95% CI 84.1-95.1) for AL and to 97.2% (91.6-99.1) for CQ. Three patients (2.8%) with recurrent parasitemia by day 28 in the CQ arm were noted to have drug levels above 100 ng/ml. CONCLUSIONS In the short term, both AL and CQ were effective and well-tolerated for P. vivax malaria, but high rates of recurrent parasitemia were noted with both drugs. CQ provided longer post-treatment prophylaxis than AL, resulting in delayed recurrence of parasitemia. Although the current policy of species-specific treatment can be maintained for Ethiopia, the co-administration of primaquine for treatment of P. vivax malaria needs to be urgently considered to prevent relapse infections. TRIAL REGISTRATION ClinicalTrials.gov NCT01052584.
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Price RN, Auburn S, Marfurt J, Cheng Q. Phenotypic and genotypic characterisation of drug-resistant Plasmodium vivax. Trends Parasitol 2012; 28:522-9. [PMID: 23044287 PMCID: PMC4627502 DOI: 10.1016/j.pt.2012.08.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 08/15/2012] [Accepted: 08/15/2012] [Indexed: 01/23/2023]
Abstract
In this review we present recent developments in the analysis of Plasmodium vivax clinical trials and ex vivo drug-susceptibility assays, as well approaches currently being used to identify molecular markers of drug resistance. Clinical trials incorporating the measurement of in vivo drug concentrations and parasite clearance times are needed to detect early signs of resistance. Analysis of P. vivax growth dynamics ex vivo have defined the criteria for acceptable assay thresholds for drug susceptibility testing, and their subsequent interpretation. Genotyping and next-generation sequencing studies in P. vivax field isolates are set to transform our understanding of the molecular mechanisms of drug resistance.
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Affiliation(s)
- Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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15
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Betuela I, Rosanas-Urgell A, Kiniboro B, Stanisic DI, Samol L, de Lazzari E, Del Portillo HA, Siba P, Alonso PL, Bassat Q, Mueller I. Relapses contribute significantly to the risk of Plasmodium vivax infection and disease in Papua New Guinean children 1-5 years of age. J Infect Dis 2012; 206:1771-80. [PMID: 22966124 DOI: 10.1093/infdis/jis580] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Plasmodium vivax forms long-lasting hypnozoites in the liver. How much they contribute to the burden of P. vivax malaria in children living in highly endemic areas is unknown. METHODS In this study, 433 Papua New Guinean children aged 1-5 years were Randomized to receive artesunate (7 days) plus primaquine (14 days), artesunate alone or no treatment and followed up actively for recurrent Plasmodium infections and disease for 40 weeks. RESULTS Treatment with artesunate-primaquine reduced the risk of P. vivax episodes by 28% (P = .042) and 33% (P = .015) compared with the artesunate and control arms, respectively. A significant reduction was observed only in the first 3 months of follow-up (artesunate-primaquine vs control, -58% [P = .004]; artesunate-primaquine vs artesunate, -49% [P = .031]) with little difference thereafter. Primaquine treatment also reduced the risk of quantitative real-time polymerase chain reaction- and light microscopy-positive P. vivax reinfections by 44% (P < .001) and 67% (P < .001), respectively. Whereas primaquine treatment did not change the risk of reinfection with Plasmodium falciparum, fewer P. falciparum clinical episodes were observed in the artesunate-primaquine arm. CONCLUSIONS Hypnozoites are an important source of P. vivax infection and contribute substantially to the high burden of P. vivax disease observed in young Papua New Guinean children. Even in highly endemic areas with a high risk of reinfection, antihypnozoite treatment should be given to all cases with parasitologically confirmed P. vivax infections.
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Affiliation(s)
- Inoni Betuela
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
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Senn N, Rarau P, Stanisic DI, Robinson L, Barnadas C, Manong D, Salib M, Iga J, Tarongka N, Ley S, Rosanas-Urgell A, Aponte JJ, Zimmerman PA, Beeson JG, Schofield L, Siba P, Rogerson SJ, Reeder JC, Mueller I. Intermittent preventive treatment for malaria in Papua New Guinean infants exposed to Plasmodium falciparum and P. vivax: a randomized controlled trial. PLoS Med 2012; 9:e1001195. [PMID: 22479155 PMCID: PMC3313928 DOI: 10.1371/journal.pmed.1001195] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 02/09/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in infants (IPTi) has been shown in randomized trials to reduce malaria-related morbidity in African infants living in areas of high Plasmodium falciparum (Pf) transmission. It remains unclear whether IPTi is an appropriate prevention strategy in non-African settings or those co-endemic for P. vivax (Pv). METHODS AND FINDINGS In this study, 1,121 Papua New Guinean infants were enrolled into a three-arm placebo-controlled randomized trial and assigned to sulfadoxine-pyrimethamine (SP) (25 mg/kg and 1.25 mg/kg) plus amodiaquine (AQ) (10 mg/kg, 3 d, n = 374), SP plus artesunate (AS) (4 mg/kg, 3 d, n = 374), or placebo (n = 373), given at 3, 6, 9 and 12 mo. Both participants and study teams were blinded to treatment allocation. The primary end point was protective efficacy (PE) against all episodes of clinical malaria from 3 to 15 mo of age. Analysis was by modified intention to treat. The PE (compared to placebo) against clinical malaria episodes (caused by all species) was 29% (95% CI, 10-43, p ≤ 0.001) in children receiving SP-AQ and 12% (95% CI, -11 to 30, p = 0.12) in those receiving SP-AS. Efficacy was higher against Pf than Pv. In the SP-AQ group, Pf incidence was 35% (95% CI, 9-54, p = 0.012) and Pv incidence was 23% (95% CI, 0-41, p = 0.048) lower than in the placebo group. IPTi with SP-AS protected only against Pf episodes (PE = 31%, 95% CI, 4-51, p = 0.027), not against Pv episodes (PE = 6%, 95% CI, -24 to 26, p = 0.759). Number of observed adverse events/serious adverse events did not differ between treatment arms (p > 0.55). None of the serious adverse events were thought to be treatment-related, and the vomiting rate was low in both treatment groups (1.4%-2.0%). No rebound in malaria morbidity was observed for 6 mo following the intervention. CONCLUSIONS IPTi using a long half-life drug combination is efficacious for the prevention of malaria and anemia in infants living in a region highly endemic for both Pf and Pv.
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Affiliation(s)
- Nicolas Senn
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Department of Medicine, University of Melbourne, Melbourne Australia
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Patricia Rarau
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Danielle I. Stanisic
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Leanne Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Céline Barnadas
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Doris Manong
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jonah Iga
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Nandao Tarongka
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Serej Ley
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | - John J. Aponte
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Peter A. Zimmerman
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - James G. Beeson
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
| | - Louis Schofield
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | | | - Ivo Mueller
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
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Kazura JW, Siba PM, Betuela I, Mueller I. Research challenges and gaps in malaria knowledge in Papua New Guinea. Acta Trop 2012; 121:274-80. [PMID: 21896268 DOI: 10.1016/j.actatropica.2011.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 08/04/2011] [Accepted: 08/07/2011] [Indexed: 10/17/2022]
Abstract
Taking into consideration the relative number of people living in Papua New Guinea the burden of malaria in this country is among the highest in Asia and the Pacific region. This article summarizes the research questions and challenges being undertaken by the Southwest Pacific International Center of Excellence for Malaria Research in the context of the epidemiology, transmission and pathogenesis of Plasmodium falciparum and P. vivax at the present time and the recent past. It is hoped that the research accomplished and local infrastructure strengthened by this effort will help inform regional and national policy with regard to the control and ultimately elimination of malaria in this region of the world.
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Barnadas C, Kent D, Timinao L, Iga J, Gray LR, Siba P, Mueller I, Thomas PJ, Zimmerman PA. A new high-throughput method for simultaneous detection of drug resistance associated mutations in Plasmodium vivax dhfr, dhps and mdr1 genes. Malar J 2011; 10:282. [PMID: 21943242 PMCID: PMC3192712 DOI: 10.1186/1475-2875-10-282] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 09/24/2011] [Indexed: 11/17/2022] Open
Abstract
Background Reports of severe cases and increasing levels of drug resistance highlight the importance of improved Plasmodium vivax case management. Whereas monitoring P. vivax resistance to anti-malarial drug by in vivo and in vitro tests remain challenging, molecular markers of resistance represent a valuable tool for high-scale analysis and surveillance studies. A new high-throughput assay for detecting the most relevant markers related to P. vivax drug resistance was developed and assessed on Papua New Guinea (PNG) patient isolates. Methods Pvdhfr, pvdhps and pvmdr1 fragments were amplified by multiplex nested PCR. Then, PCR products were processed through an LDR-FMA (ligase detection reaction - fluorescent microsphere assay). 23 SNPs, including pvdhfr 57-58-61 and 173, pvdhps 382-383, 553, 647 and pvmdr1 976, were simultaneously screened in 366 PNG P. vivax samples. Results Genotyping was successful in 95.4% of the samples for at least one gene. The coexistence of multiple distinct haplotypes in the parasite population necessitated the introduction of a computer-assisted approach to data analysis. Whereas 73.1% of patients were infected with at least one wild-type genotype at codons 57, 58 and 61 of pvdhfr, a triple mutant genotype was detected in 65.6% of the patients, often associated with the 117T mutation. Only one patient carried the 173L mutation. The mutant 647P pvdhps genotype allele was approaching genetic fixation (99.3%), whereas 35.1% of patients were infected with parasites carrying the pvmdr1 976F mutant allele. Conclusions The LDR-FMA described here allows a discriminant genotyping of resistance alleles in the pvdhfr, pvdhps, and pvmdr1 genes and can be used in large-scale surveillance studies.
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Affiliation(s)
- Céline Barnadas
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
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