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Rosenthal PJ, Asua V, Bailey JA, Conrad MD, Ishengoma DS, Kamya MR, Rasmussen C, Tadesse FG, Uwimana A, Fidock DA. The emergence of artemisinin partial resistance in Africa: how do we respond? THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00141-5. [PMID: 38552654 DOI: 10.1016/s1473-3099(24)00141-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 04/21/2024]
Abstract
Malaria remains one of the most important infectious diseases in the world, with the greatest burden in sub-Saharan Africa, primarily from Plasmodium falciparum infection. The treatment and control of malaria is challenged by resistance to most available drugs, but partial resistance to artemisinins (ART-R), the most important class for the treatment of malaria, was until recently confined to southeast Asia. This situation has changed, with the emergence of ART-R in multiple countries in eastern Africa. ART-R is mediated primarily by single point mutations in the P falciparum kelch13 protein, with several mutations present in African parasites that are now validated resistance mediators based on clinical and laboratory criteria. Major priorities at present are the expansion of genomic surveillance for ART-R mutations across the continent, more frequent testing of the efficacies of artemisinin-based regimens against uncomplicated and severe malaria in trials, more regular assessment of ex-vivo antimalarial drug susceptibilities, consideration of changes in treatment policy to deter the spread of ART-R, and accelerated development of new antimalarial regimens to overcome the impacts of ART-R. The emergence of ART-R in Africa is an urgent concern, and it is essential that we increase efforts to characterise its spread and mitigate its impact.
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Affiliation(s)
- Philip J Rosenthal
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda; University of Tübingen, Tübingen, Germany
| | - Jeffrey A Bailey
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA; Departments of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Melissa D Conrad
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania; Department of Biochemistry, Kampala International University in Tanzania, Dar es Salaam, Tanzania; School of Public Health, Harvard University, Boston, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Fitsum G Tadesse
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia; London School of Hygiene and Tropical Medicine, London, UK
| | - Aline Uwimana
- Rwanda Biomedical Center, Kigali, Rwanda; Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - David A Fidock
- Department of Microbiology and Immunology and Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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2
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van Schalkwyk DA, Pratt S, Nolder D, Stewart LB, Liddy H, Muwanguzi-Karugaba J, Beshir KB, Britten D, Victory E, Rogers C, Millard J, Brown M, Nabarro LE, Taylor A, Young BC, Chiodini PL, Sutherland CJ. Treatment Failure in a UK Malaria Patient Harboring Genetically Variant Plasmodium falciparum From Uganda With Reduced In Vitro Susceptibility to Artemisinin and Lumefantrine. Clin Infect Dis 2024; 78:445-452. [PMID: 38019958 PMCID: PMC10874266 DOI: 10.1093/cid/ciad724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Recent cases of clinical failure in malaria patients in the United Kingdom (UK) treated with artemether-lumefantrine have implications for malaria chemotherapy worldwide. METHODS Parasites were isolated from an index case of confirmed Plasmodium falciparum treatment failure after standard treatment, and from comparable travel-acquired UK malaria cases. Drug susceptibility in vitro and genotypes at 6 resistance-associated loci were determined for all parasite isolates and compared with clinical outcomes for each parasite donor. RESULTS A traveler, who returned to the UK from Uganda in 2022 with Plasmodium falciparum malaria, twice failed treatment with full courses of artemether-lumefantrine. Parasites from the patient exhibited significantly reduced susceptibility to artemisinin (ring-stage survival, 17.3% [95% confidence interval {CI}, 13.6%-21.1%]; P < .0001) and lumefantrine (effective concentration preventing 50% of growth = 259.4 nM [95% CI, 130.6-388.2 nM]; P = .001). Parasite genotyping identified an allele of pfk13 encoding both the A675V variant in the Pfk13 propeller domain and a novel L145V nonpropeller variant. In vitro susceptibility testing of 6 other P. falciparum lines of Ugandan origin identified reduced susceptibility to artemisinin and lumefantrine in 1 additional line, also from a 2022 treatment failure case. These parasites did not harbor a pfk13 propeller domain variant but rather the novel nonpropeller variant T349I. Variant alleles of pfubp1, pfap2mu, and pfcoronin were also identified among the 7 parasite lines. CONCLUSIONS We confirm, in a documented case of artemether-lumefantrine treatment failure imported from Uganda, the presence of pfk13 mutations encoding L145V and A675V. Parasites with reduced susceptibility to both artemisinin and lumefantrine may be emerging in Uganda.
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Affiliation(s)
- Donelly A van Schalkwyk
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sade Pratt
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Debbie Nolder
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lindsay B Stewart
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Liddy
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julian Muwanguzi-Karugaba
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Khalid B Beshir
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dawn Britten
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emma Victory
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Claire Rogers
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James Millard
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Laura E Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew Taylor
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Bernadette C Young
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Peter L Chiodini
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Colin J Sutherland
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- UK Health Security Agency Malaria Reference Laboratory, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Zupko RJ, Nguyen TD, Ngabonziza JCS, Kabera M, Li H, Tran TNA, Tran KT, Uwimana A, Boni MF. Modeling policy interventions for slowing the spread of artemisinin-resistant pfkelch R561H mutations in Rwanda. Nat Med 2023; 29:2775-2784. [PMID: 37735560 PMCID: PMC10667088 DOI: 10.1038/s41591-023-02551-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/18/2023] [Indexed: 09/23/2023]
Abstract
Artemisinin combination therapies (ACTs) are highly effective at treating uncomplicated Plasmodium falciparum malaria, but the emergence of the new pfkelch13 R561H mutation in Rwanda, associated with delayed parasite clearance, suggests that interventions are needed to slow its spread. Using a Rwanda-specific spatial calibration of an individual-based malaria model, we evaluate 26 strategies aimed at minimizing treatment failures and delaying the spread of R561H after 3, 5 and 10 years. Lengthening ACT courses and deploying multiple first-line therapies (MFTs) reduced treatment failures after 5 years when compared to the current approach of a 3-d course of artemether-lumefantrine. The best among these options (an MFT policy) resulted in median treatment failure counts that were 49% lower and a median R561H allele frequency that was 0.15 lower than under baseline. New approaches to resistance management, such as triple ACTs or sequential courses of two different ACTs, were projected to have a larger impact than longer ACT courses or MFT; these were associated with median treatment failure counts in 5 years that were 81-92% lower than the current approach. A policy response to currently circulating artemisinin-resistant genotypes in Africa is urgently needed to prevent a population-wide rise in treatment failures.
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Affiliation(s)
- Robert J Zupko
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA.
| | - Tran Dang Nguyen
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
| | - J Claude S Ngabonziza
- Research, Innovation and Data Science Division, Rwanda Biomedical Center (RBC), Kigali, Rwanda
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
| | - Michee Kabera
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre (RBC), Kigali, Rwanda
| | - Haojun Li
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
- Department of Computer Science, Columbia University, New York City, NY, USA
| | - Thu Nguyen-Anh Tran
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
| | - Kien Trung Tran
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
| | - Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre (RBC), Kigali, Rwanda
- Louvain Drug Research Institute, Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Maciej F Boni
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA, USA
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Persistence of Residual Submicroscopic P. falciparum Parasitemia following Treatment of Artemether-Lumefantrine in Ethio-Sudan Border, Western Ethiopia. Antimicrob Agents Chemother 2022; 66:e0000222. [PMID: 35993723 PMCID: PMC9487599 DOI: 10.1128/aac.00002-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The emergence of artemisinin-resistant parasites in Africa has had a devastating impact, causing most malaria cases and related deaths reported on the continent. In Ethiopia, artemether-lumefantrine (AL) is the first-line drug for the treatment of uncomplicated falciparum malaria. This study is one of the earliest evaluations of artemether-lumefantrine (AL) efficacy in western Ethiopia, 17 years after the introduction of this drug in the study area. This study aimed at assessing PCR- corrected clinical and parasitological responses at 28 days following AL treatment. Sixty uncomplicated falciparum malaria patients were enrolled, treated with standard doses of AL, and monitored for 28 days with clinical and parasitological assessments from September 15 to December 15, 2020. Microscopy was used for patient recruitment and molecular diagnosis of P. falciparum was performed by Var gene acidic terminal sequence (varATS) real-time PCR on dried blood spots collected from each patient from day 0 and on follow-up days 1, 2, 3, 7, 14, 21, and 28. MspI and msp2 genotyping was done to confirm occurrence of recrudescence. Data entry and analysis were done by using the WHO-designed Excel spreadsheet and SPSS version 20 for Windows. A P value of less or equal to 0.05 was considered significant. From a total of 60 patients enrolled in this efficacy study, 10 were lost to follow-up; the results were analyzed for 50 patients. All the patients were fever-free on day 3. The asexual parasite positivity rate on day 3 was zero. However; 60% of the patients were PCR positive on day 3. PCR positivity on day 3 was more common among patients <15 years old as compared with those ≥15 years old (AOR = 6.44, P = 0.027). Only two patients met the case definition of treatment failure. These patients were classified as a late clinical failure as they showed symptoms of malaria and asexual stages of the parasite detected by microscopy on day 14 of their follow-ups. Hence, the Kaplan-Meier analysis of PCR- corrected adequate clinical and parasitological response (ACPR) rate of AL among study participants was 96% (95% CI: 84.9-99). In seven patients, the residual submicroscopic parasitemia persists from day 0 to day 28 of the follow-up. In addition, 16% (8/50) of patients were PCR- and then turned PCR+ after day 7 of the follow-up. AL remains efficacious for the treatment of uncomplicated falciparum malaria in the study area. However, the persistence of PCR-detected residual submicroscopic parasitemia following AL might compromise this treatment and need careful monitoring.
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Auparakkitanon S, Wilairat P, Wilairat P. Will the in situ activator(s) of artemisinin please stand up? Mol Biochem Parasitol 2022; 248:111461. [DOI: 10.1016/j.molbiopara.2022.111461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
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Small-Saunders JL, Hagenah LM, Wicht KJ, Dhingra SK, Deni I, Kim J, Vendome J, Gil-Iturbe E, Roepe PD, Mehta M, Mancia F, Quick M, Eppstein MJ, Fidock DA. Evidence for the early emergence of piperaquine-resistant Plasmodium falciparum malaria and modeling strategies to mitigate resistance. PLoS Pathog 2022; 18:e1010278. [PMID: 35130315 PMCID: PMC8853508 DOI: 10.1371/journal.ppat.1010278] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/17/2022] [Accepted: 01/13/2022] [Indexed: 11/19/2022] Open
Abstract
Multidrug-resistant Plasmodium falciparum parasites have emerged in Cambodia and neighboring countries in Southeast Asia, compromising the efficacy of first-line antimalarial combinations. Dihydroartemisinin + piperaquine (PPQ) treatment failure rates have risen to as high as 50% in some areas in this region. For PPQ, resistance is driven primarily by a series of mutant alleles of the P. falciparum chloroquine resistance transporter (PfCRT). PPQ resistance was reported in China three decades earlier, but the molecular driver remained unknown. Herein, we identify a PPQ-resistant pfcrt allele (China C) from Yunnan Province, China, whose genotypic lineage is distinct from the PPQ-resistant pfcrt alleles currently observed in Cambodia. Combining gene editing and competitive growth assays, we report that PfCRT China C confers moderate PPQ resistance while re-sensitizing parasites to chloroquine (CQ) and incurring a fitness cost that manifests as a reduced rate of parasite growth. PPQ transport assays using purified PfCRT isoforms, combined with molecular dynamics simulations, highlight differences in drug transport kinetics and in this transporter’s central cavity conformation between China C and the current Southeast Asian PPQ-resistant isoforms. We also report a novel computational model that incorporates empirically determined fitness landscapes at varying drug concentrations, combined with antimalarial susceptibility profiles, mutation rates, and drug pharmacokinetics. Our simulations with PPQ-resistant or -sensitive parasite lines predict that a three-day regimen of PPQ combined with CQ can effectively clear infections and prevent the evolution of PfCRT variants. This work suggests that including CQ in combination therapies could be effective in suppressing the evolution of PfCRT-mediated multidrug resistance in regions where PPQ has lost efficacy. The recent emergence of Plasmodium falciparum parasite resistance to the antimalarial drug piperaquine (PPQ) has contributed to frequent treatment failures across Southeast Asia, originating in Cambodia. Here, we show that earlier reports of PPQ resistance in Yunnan Province, China could be explained by the unique China C variant of the P. falciparum chloroquine resistance transporter PfCRT. Gene-edited parasites show a loss of fitness and parasite resensitization to the chemically related former first-line antimalarial chloroquine, while acquiring PPQ resistance via drug efflux. Molecular features of drug resistance were examined using biochemical assays to measure mutant PfCRT-mediated drug transport and molecular dynamics simulations with the recently solved PfCRT structure to assess changes in the central drug-binding cavity. We also describe a new computational model that incorporates parasite mutation rates, fitness costs, antimalarial susceptibilities, and drug pharmacological profiles to predict how infections with parasite strains expressing distinct PfCRT variants can evolve and be selected in response to different drug pressures and regimens. Simulations predict that a three-day regimen of PPQ plus chloroquine would be fully effective at preventing recrudescence of drug-resistant infections.
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Affiliation(s)
- Jennifer L Small-Saunders
- Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Laura M Hagenah
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Kathryn J Wicht
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Satish K Dhingra
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Ioanna Deni
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Jonathan Kim
- Department of Physiology and Cellular Biophysics, Columbia University Irving Medical Center, New York, New York United States of America
| | - Jeremie Vendome
- Schrödinger, Inc., New York, New York, United States of America
| | - Eva Gil-Iturbe
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Paul D Roepe
- Department of Chemistry, Georgetown University, Washington, DC, United States of America
- Department of Biochemistry and Cellular and Molecular Biology, Georgetown University, Washington, DC, United States of America
| | - Monica Mehta
- Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Filippo Mancia
- Department of Physiology and Cellular Biophysics, Columbia University Irving Medical Center, New York, New York United States of America
| | - Matthias Quick
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, United States of America
- Division of Molecular Therapeutics, New York State Psychiatric Institute, New York, New York, United States of America
- Center for Molecular Recognition, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Margaret J Eppstein
- Vermont Complex Systems Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Computer Science, University of Vermont, Burlington, Vermont, United States of America
- Translational Global Infectious Diseases Research Center, University of Vermont, Burlington, Vermont, United States of America
| | - David A Fidock
- Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, New York, United States of America
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Mesén-Ramírez P, Bergmann B, Elhabiri M, Zhu L, von Thien H, Castro-Peña C, Gilberger TW, Davioud-Charvet E, Bozdech Z, Bachmann A, Spielmann T. The parasitophorous vacuole nutrient channel is critical for drug access in malaria parasites and modulates the artemisinin resistance fitness cost. Cell Host Microbe 2021; 29:1774-1787.e9. [PMID: 34863371 DOI: 10.1016/j.chom.2021.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/14/2021] [Accepted: 11/03/2021] [Indexed: 02/08/2023]
Abstract
Intraerythrocytic malaria parasites proliferate bounded by a parasitophorous vacuolar membrane (PVM). The PVM contains nutrient permeable channels (NPCs) conductive to small molecules, but their relevance for parasite growth for individual metabolites is largely untested. Here we show that growth-relevant levels of major carbon and energy sources pass through the NPCs. Moreover, we find that NPCs are a gate for several antimalarial drugs, highlighting their permeability properties as a critical factor for drug design. Looking into NPC-dependent amino acid transport, we find that amino acid shortage is a reason for the fitness cost in artemisinin-resistant (ARTR) parasites and provide evidence that NPC upregulation to increase amino acids acquisition is a mechanism of ARTR parasites in vitro and in human infections to compensate this fitness cost. Hence, the NPCs are important for nutrient and drug access and reveal amino acid deprivation as a critical constraint in ARTR parasites.
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Affiliation(s)
- Paolo Mesén-Ramírez
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany
| | - Bärbel Bergmann
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany
| | - Mourad Elhabiri
- UMR7042 Université de Strasbourg‒CNRS‒UHA, Laboratoire d'Innovation Moléculaire et Applications (LIMA), Team Bio(IN)organic and Medicinal Chemistry, European School of Chemistry, Polymers and Materials (ECPM), 25 Rue Becquerel, F-67087 Strasbourg, France
| | - Lei Zhu
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore 637551, Singapore
| | - Heidrun von Thien
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany; Centre for Structural Systems Biology, Notkestraße 85, Building 15, 22607, University of Hamburg, 20146 Hamburg, Germany
| | - Carolina Castro-Peña
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany
| | - Tim-Wolf Gilberger
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany; Centre for Structural Systems Biology, Notkestraße 85, Building 15, 22607, University of Hamburg, 20146 Hamburg, Germany
| | - Elisabeth Davioud-Charvet
- UMR7042 Université de Strasbourg‒CNRS‒UHA, Laboratoire d'Innovation Moléculaire et Applications (LIMA), Team Bio(IN)organic and Medicinal Chemistry, European School of Chemistry, Polymers and Materials (ECPM), 25 Rue Becquerel, F-67087 Strasbourg, France
| | - Zbynek Bozdech
- School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, Singapore 637551, Singapore; Honorary Visiting Research Fellow, Nuffield Department of Medicine, University of Oxford, UK
| | - Anna Bachmann
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany; Centre for Structural Systems Biology, Notkestraße 85, Building 15, 22607, University of Hamburg, 20146 Hamburg, Germany
| | - Tobias Spielmann
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Str. 74, 20359 Hamburg, Germany.
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Kümpornsin K, Loesbanluechai D, de Cozar C, Kotanan N, Chotivanich K, White NJ, Wilairat P, Gomez-Lorenzo MG, Gamo FJ, Sanz LM, Lee MCS, Chookajorn T. Lumefantrine attenuates Plasmodium falciparum artemisinin resistance during the early ring stage. INTERNATIONAL JOURNAL FOR PARASITOLOGY-DRUGS AND DRUG RESISTANCE 2021; 17:186-190. [PMID: 34673330 PMCID: PMC8528645 DOI: 10.1016/j.ijpddr.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
Emerging artemisinin resistance in Plasmodium falciparum malaria has the potential to become a global public health crisis. In Southeast Asia, this phenomenon clinically manifests in the form of delayed parasite clearance following artemisinin treatment. Reduced artemisinin susceptibility is limited to the early ring stage window, which is sufficient to allow parasites to survive the short half-life of artemisinin exposure. A screen of known clinically-implemented antimalarial drugs was performed to identify a drug capable of enhancing the killing activity of artemisinins during this critical resistance window. As a result, lumefantrine was found to increase the killing activity of artemisinin against an artemisinin-resistant clinical isolate harboring the C580Y kelch13 mutation. Isobologram analysis revealed synergism during the early ring stage resistance window, when lumefantrine was combined with artemether, an artemisinin derivative clinically partnered with lumefantrine. These findings suggest that lumefantrine should be clinically explored as a partner drug in artemisinin-based combination therapies to control emerging artemisinin resistance. Artemisinin booster compound screening targeting the early ring resistance window in Plasmodium falciparum was performed. Lumefantrine improves the activity of artesunate against the parasite during the resistance window. Artemether and lumefantrine are synergistic during the early ring stage resistance window.
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Affiliation(s)
| | - Duangkamon Loesbanluechai
- Genomics and Evolutionary Medicine Unit (GEM), Centre of Excellence in Malaria Research, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Molecular Medicine Program, Multidisciplinary Unit, Faculty of Science, Mahidol University, Bangkok, Thailand
| | | | - Namfon Kotanan
- Genomics and Evolutionary Medicine Unit (GEM), Centre of Excellence in Malaria Research, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kesinee Chotivanich
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Mahidol-Oxford Tropical Medicine Research Unit, 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 Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Prapon Wilairat
- Department of Biochemistry, Faculty of Science, Mahidol University, Bangkok, Thailand
| | | | | | | | - Marcus C S Lee
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK.
| | - Thanat Chookajorn
- Genomics and Evolutionary Medicine Unit (GEM), Centre of Excellence in Malaria Research, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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9
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Sutherland CJ, Henrici RC, Artavanis-Tsakonas K. Artemisinin susceptibility in the malaria parasite Plasmodium falciparum: propellers, adaptor proteins and the need for cellular healing. FEMS Microbiol Rev 2021; 45:fuaa056. [PMID: 33095255 PMCID: PMC8100002 DOI: 10.1093/femsre/fuaa056] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022] Open
Abstract
Studies of the susceptibility of Plasmodium falciparum to the artemisinin family of antimalarial drugs provide a complex picture of partial resistance (tolerance) associated with increased parasite survival in vitro and in vivo. We present an overview of the genetic loci that, in mutant form, can independently elicit parasite tolerance. These encode Kelch propeller domain protein PfK13, ubiquitin hydrolase UBP-1, actin filament-organising protein Coronin, also carrying a propeller domain, and the trafficking adaptor subunit AP-2μ. Detailed studies of these proteins and the functional basis of artemisinin tolerance in blood-stage parasites are enabling a new synthesis of our understanding to date. To guide further experimental work, we present two major conclusions. First, we propose a dual-component model of artemisinin tolerance in P. falciparum comprising suppression of artemisinin activation in early ring stage by reducing endocytic haemoglobin capture from host cytosol, coupled with enhancement of cellular healing mechanisms in surviving cells. Second, these two independent requirements limit the likelihood of development of complete artemisinin resistance by P. falciparum, favouring deployment of existing drugs in new schedules designed to exploit these biological limits, thus extending the useful life of current combination therapies.
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Affiliation(s)
- Colin J Sutherland
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Ryan C Henrici
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia 19104, PA, USA
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10
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Ansbro MR, Itkin Z, Chen L, Zahoranszky-Kohalmi G, Amaratunga C, Miotto O, Peryea T, Hobbs CV, Suon S, Sá JM, Dondorp AM, van der Pluijm RW, Wellems TE, Simeonov A, Eastman RT. Modulation of Triple Artemisinin-Based Combination Therapy Pharmacodynamics by Plasmodium falciparum Genotype. ACS Pharmacol Transl Sci 2020; 3:1144-1157. [PMID: 33344893 PMCID: PMC7737215 DOI: 10.1021/acsptsci.0c00110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 01/19/2023]
Abstract
The first-line treatments for uncomplicated Plasmodium falciparum malaria are artemisinin-based combination therapies (ACTs), consisting of an artemisinin derivative combined with a longer acting partner drug. However, the spread of P. falciparum with decreased susceptibility to artemisinin and partner drugs presents a significant challenge to malaria control efforts. To stem the spread of drug resistant parasites, novel chemotherapeutic strategies are being evaluated, including the implementation of triple artemisinin-based combination therapies (TACTs). Currently, there is limited knowledge on the pharmacodynamic and pharmacogenetic interactions of proposed TACT drug combinations. To evaluate these interactions, we established an in vitro high-throughput process for measuring the drug concentration-response to three distinct antimalarial drugs present in a TACT. Sixteen different TACT combinations were screened against 15 parasite lines from Cambodia, with a focus on parasites with differential susceptibilities to piperaquine and artemisinins. Analysis revealed drug-drug interactions unique to specific genetic backgrounds, including antagonism between piperaquine and pyronaridine associated with gene amplification of plasmepsin II/III, two aspartic proteases that localize to the parasite digestive vacuole. From this initial study, we identified parasite genotypes with decreased susceptibility to specific TACTs, as well as potential TACTs that display antagonism in a genotype-dependent manner. Our assay and analysis platform can be further leveraged to inform drug implementation decisions and evaluate next-generation TACTs.
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Affiliation(s)
- Megan R. Ansbro
- Laboratory of Malaria
and Vector Research, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Maryland 20892, United States
- Wellcome Sanger Institute, Hinxton CB10 1SA, U.K.
| | - Zina Itkin
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
| | - Lu Chen
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
| | - Gergely Zahoranszky-Kohalmi
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
| | - Chanaki Amaratunga
- Laboratory of Malaria
and Vector Research, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Olivo Miotto
- Wellcome Sanger Institute, Hinxton CB10 1SA, U.K.
- Mahidol-Oxford Tropical Medicine Research
Unit, Faculty of Tropical Medicine, Mahidol
University, Bangkok 10400, Thailand
- Centre
for Tropical Medicine and Global Health, Nuffield Department of Medicine
Research, University of Oxford, Oxford OX3 7LF, U.K.
- Medical Research Council (MRC) Centre for Genomics and
Global Health, University of Oxford, Oxford OX3 7BN, U.K.
| | - Tyler Peryea
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Children’s
Hospital, University of Mississippi Medical
Center, Jackson, Mississippi 39216, United States
| | - Seila Suon
- National Center for Parasitology, Entomology,
and Malaria Control, Phnom Penh, Cambodia
| | - Juliana M. Sá
- Laboratory of Malaria
and Vector Research, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research
Unit, Faculty of Tropical Medicine, Mahidol
University, Bangkok 10400, Thailand
- Centre
for Tropical Medicine and Global Health, Nuffield Department of Medicine
Research, University of Oxford, Oxford OX3 7LF, U.K.
| | - Rob W. van der Pluijm
- Mahidol-Oxford Tropical Medicine Research
Unit, Faculty of Tropical Medicine, Mahidol
University, Bangkok 10400, Thailand
- Centre
for Tropical Medicine and Global Health, Nuffield Department of Medicine
Research, University of Oxford, Oxford OX3 7LF, U.K.
| | - Thomas E. Wellems
- Laboratory of Malaria
and Vector Research, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Anton Simeonov
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
| | - Richard T. Eastman
- National
Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Rockville, Maryland 20850, United States
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11
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Sutherland CJ. A New Window on Plasmodium malariae Infections. J Infect Dis 2020; 221:864-866. [PMID: 30855671 DOI: 10.1093/infdis/jiz103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Colin J Sutherland
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
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12
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Khoury DS, Cao P, Zaloumis SG, Davenport MP. Artemisinin Resistance and the Unique Selection Pressure of a Short-acting Antimalarial. Trends Parasitol 2020; 36:884-887. [DOI: 10.1016/j.pt.2020.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 01/05/2023]
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13
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Lubis IND, Wijaya H, Lubis M, Lubis CP, Beshir KB, Staedke SG, Sutherland CJ. Recurrence of Plasmodium malariae and P. falciparum Following Treatment of Uncomplicated Malaria in North Sumatera With Dihydroartemisinin-Piperaquine or Artemether-Lumefantrine. Open Forum Infect Dis 2020; 7:ofaa116. [PMID: 32420402 PMCID: PMC7216766 DOI: 10.1093/ofid/ofaa116] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/01/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We assessed the efficacy of artemisinin-based combination therapies for treatment of uncomplicated falciparum malaria, with or without co-infecting Plasmodium spp., in Sumatera, Indonesia. METHODS Febrile patients aged >6 months with uncomplicated P. falciparum were randomized to receive dihydroartemisinin-piperaquine or artemether-lumefantrine, plus single-dose primaquine, and were followed for 42 days. Mixed Plasmodium infections were included; P. vivax infections received 14 days of primaquine. We retrospectively restricted the analysis to cases with polymerase chain reaction (PCR)-confirmed parasitemia. Recurrent parasitemia in follow-up was identified by species-specific nested PCR. RESULTS Of the 3731 participants screened, 302 were enrolled and randomized. In the dihydroartemisinin-piperaquine arm, P. falciparum infections were confirmed by PCR in 59 participants, with mixed infections in 23 (39.0%). In the artemether-lumefantrine arm, P. falciparum infections were confirmed by PCR in 55 participants, with mixed infections in 16 (29.0%). Both regimens were well tolerated, and symptoms improved rapidly in all treated participants. In the dihydroartemisinin-piperaquine arm, 1 P. falciparum recurrence (on day 7) and 6 P. malariae recurrences (1 had a mixed infection with P. falciparum) were identified during days 3-42 of follow-up. In the artemether-lumefantrine arm, 1 P. falciparum/P. malariae/P. vivax recurrence occurred on day 35. Submicroscopic persistence occurred during follow-up in 21 (37%) of 57 receiving dihydroartemisinin-piperaquine and 20 (39%) of 51 receiving artemether-lumefantrine. CONCLUSIONS In Sumatera, both regimens effectively cleared initial parasitemia, but P. falciparum and P. malariae persisted in some individuals. Molecular species detection should be deployed in antimalarial efficacy trials in Indonesia. TRIAL REGISTRATION NCT02325180.
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Affiliation(s)
- Inke Nadia D Lubis
- Department of Paediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
- Infection and Immunity Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Hendri Wijaya
- Department of Paediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Munar Lubis
- Department of Paediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Chairuddin P Lubis
- Department of Paediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Khalid B Beshir
- Infection and Immunity Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sarah G Staedke
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Colin J Sutherland
- Infection and Immunity Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- PHE Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, London, United Kingdom
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14
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Modification of pfap2μ and pfubp1 Markedly Reduces Ring-Stage Susceptibility of Plasmodium falciparum to Artemisinin In Vitro. Antimicrob Agents Chemother 2019; 64:AAC.01542-19. [PMID: 31636063 DOI: 10.1128/aac.01542-19] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/10/2019] [Indexed: 12/26/2022] Open
Abstract
Management of uncomplicated malaria worldwide is threatened by the emergence in Asia of Plasmodium falciparum carrying variants of the pfk13 locus and exhibiting reduced susceptibility to artemisinin. Mutations in two other genes, ubp1 and ap2μ, are associated with artemisinin resistance in rodent malaria and with clinical failure of combination therapy in African malaria patients. Transgenic P. falciparum clones, each carrying orthologues of mutations in pfap2μ and pfubp1 associated with artemisinin resistance in Plasmodium chabaudi, were derived by Cas9 gene editing. Susceptibility to artemisinin and other antimalarial drugs was determined. Following exposure to 700 nM dihydroartemisinin in the ring-stage survival assay, we found strong evidence that transgenic parasites expressing the I592T variant (11% survival), but not the S160N variant (1% survival), of the AP2μ adaptin subunit were significantly less susceptible than the parental wild-type parasite population. The V3275F variant of UBP1, but not the V3306F variant, also displayed reduced susceptibility to dihydroartemisinin (8.5% survival versus 0.5% survival). AP2μ and UBP1 variants did not elicit reduced susceptibility to 48 h of exposure to artemisinin or to other antimalarial drugs. Therefore, variants of the AP2 adaptor complex μ-subunit and of the ubiquitin hydrolase UBP1 reduce in vitro artemisinin susceptibility at the early ring stage in P. falciparum These findings confirm the existence of multiple pathways to perturbation of either the mode of action of artemisinin, the parasite's adaptive mechanisms of resistance, or both. The cellular role of UBP1 and AP2μ in Plasmodium parasites should now be elucidated.
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Abstract
Intensified treatment and control efforts since the early 2000s have dramatically reduced the burden of Plasmodium falciparum malaria. However, drug resistance threatens to derail this progress. In this review, we present four antimalarial resistance case studies that differ in timeline, technical approaches, mechanisms of action, and categories of resistance: chloroquine, sulfadoxine-pyrimethamine, artemisinin, and piperaquine. Lessons learned from prior losses of treatment efficacy, drug combinations, and control strategies will help advance mechanistic research into how P. falciparum parasites acquire resistance to current first-line artemisinin-based combination therapies. Understanding resistance in the clinic and laboratory is essential to prolong the effectiveness of current antimalarial drugs and to optimize the pipeline of future medicines.
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Affiliation(s)
- Leila S Ross
- Department of Microbiology & Immunology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - David A Fidock
- Department of Microbiology & Immunology, Columbia University Irving Medical Center, New York, NY 10032, USA; Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA.
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16
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Grande R, Antinori S, Meroni L, Menegon M, Severini C. A case of Plasmodium malariae recurrence: recrudescence or reinfection? Malar J 2019; 18:169. [PMID: 31088460 PMCID: PMC6515619 DOI: 10.1186/s12936-019-2806-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Plasmodium malariae is the most neglected of the six human malaria species and it is still unknown which is the mechanism underlying the long latency of this Plasmodium. CASE PRESENTATION A case of PCR-confirmed P. malariae recurrence in a 52-year old Italian man was observed 5 months after a primary attack. In the interval between the two observed episodes of malaria the patient denied any further stay in endemic areas except for a visit to Libya, a country considered malaria-free. Genomic DNA of the P. malariae strain using five microsatellites (PM2, PM9, PM11, PM25, PM34) and the antigen marker of circumsporozoite (csp) was amplified and sequenced. Analysis of polymorphisms of the P. malariae csp central repeat region showed differences between the strains responsible of the first and second episode of malaria. A difference in the allele size was also observed for the sequence analysis of PM2 microsatellites. CONCLUSIONS Plasmodium malariae is a challenging human malaria parasite and even with the use of molecular techniques the pathogenesis of recurrent episodes cannot be precisely explained.
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Affiliation(s)
- Romualdo Grande
- Clinical Microbiology, Virology and Bioemergency, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy.
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy.
| | - Luca Meroni
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Michela Menegon
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Carlo Severini
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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17
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Okell LC, Reiter LM, Ebbe LS, Baraka V, Bisanzio D, Watson OJ, Bennett A, Verity R, Gething P, Roper C, Alifrangis M. Emerging implications of policies on malaria treatment: genetic changes in the Pfmdr-1 gene affecting susceptibility to artemether-lumefantrine and artesunate-amodiaquine in Africa. BMJ Glob Health 2018; 3:e000999. [PMID: 30397515 PMCID: PMC6202998 DOI: 10.1136/bmjgh-2018-000999] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/21/2018] [Accepted: 08/31/2018] [Indexed: 11/04/2022] Open
Abstract
Artemether–lumefantrine (AL) and artesunate–amodiaquine (AS-AQ) are the most commonly used artemisinin-based combination therapies (ACT) for treatment of Plasmodium falciparum in Africa. Both treatments remain efficacious, but single nucleotide polymorphisms (SNPs) in the Plasmodium falciparum multidrug resistance 1 (Pfmdr1) gene may compromise sensitivity. AL and AS-AQ exert opposing selective pressures: parasites with genotype 86Y, Y184 and 1246Y are partially resistant to AS-AQ treatment, while N86, 184 F and D1246 are favoured by AL treatment. Through a systematic review, we identified 397 surveys measuring the prevalence of Pfmdr1 polymorphisms at positions 86 184 or 1246 in 30 countries in Africa. Temporal trends in SNP frequencies after introduction of AL or AS-AQ as first-line treatment were analysed in 32 locations, and selection coefficients estimated. We examined associations between antimalarial policies, consumption, transmission intensity and rate of SNP selection. 1246Y frequency decreased on average more rapidly in locations where national policy recommended AL (median selection coefficient(s) of −0.083), compared with policies of AS-AQ or both AL and AS-AQ (median s=−0.035 and 0.021, p<0.001 respectively). 86Y frequency declined markedly after ACT policy introduction, with a borderline significant trend for a more rapid decline in countries with AL policies (p=0.055). However, these trends could also be explained by a difference in initial SNP frequencies at the time of ACT introduction. There were non-significant trends for faster selection of N86 and D1246 in areas with higher AL consumption and no trend with transmission intensity. Recorded consumption of AS-AQ was low in the locations and times Pfmdr1 data were collected. SNP trends in countries with AL policies suggest a broad increase in sensitivity of parasites to AS-AQ, by 7–10 years after AL introduction. Observed rates of selection have implications for planning strategies to cycle drugs or use multiple first-line therapies to maintain drug efficacy.
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Affiliation(s)
- Lucy C Okell
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Lisa Malene Reiter
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lene Sandø Ebbe
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Disease, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vito Baraka
- Department of Biomedical Sciences, National Institute for Medical Research, Tanga, United Republic of Tanzania
| | - Donal Bisanzio
- RTI International, Washington, District of Columbia, USA
| | - Oliver J Watson
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of San FranciscO, San Francisco, California, USA
| | - Robert Verity
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Peter Gething
- Malaria Atlas Project, Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Cally Roper
- Department of Pathogen Molecular Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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Patients' Knowledge of Artemisinin-Based Combination Therapy Treatment and Its Impact on Patient Adherence. J Trop Med 2018; 2018:7465254. [PMID: 30105056 PMCID: PMC6076912 DOI: 10.1155/2018/7465254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/09/2018] [Accepted: 06/20/2018] [Indexed: 11/17/2022] Open
Abstract
Despite increased support from government and other stakeholders for malaria control over the past decade, malaria burden remains high in many endemic countries, particularly in Sub-Saharan Africa. This study aimed to assess patients' knowledge of antimalarial treatment (ACT) and its association with patient adherence. A descriptive cross-sectional study design was employed in this study. Data were collected from April to May 2017. Both descriptive and inferential statistics in the form of frequencies, percentages, mean values, standard deviations, and Pearson's chi-square test were generated by use of Microsoft excel spreadsheet and IBM Statistical Package for Social Sciences (SPSS) version 23. The average age of the respondents surveyed for this study was 42.27 ± 11.09. Adherence level to ACT was 47%. The results showed that there was a significant association between respondents' knowledge of the efficacy of antimalarial medication (p = 0.003), benefits of completing antimalarial treatment course (p = 0.001), and consequences of not completing the doses of antimalarial medication prescribed (p = 0.002) and adherence to ACT. This study then recommends that improving patients' knowledge regarding the efficacy, benefits of completing ACT, and consequences of not completing ACT treatment may improve the likelihood of patients adhering fully to ACT.
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19
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Hooft van Huijsduijnen R, Wells TN. The antimalarial pipeline. Curr Opin Pharmacol 2018; 42:1-6. [PMID: 29860174 DOI: 10.1016/j.coph.2018.05.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/03/2018] [Accepted: 05/16/2018] [Indexed: 12/12/2022]
Abstract
Over the past decade, new high-throughput phenotypic assays with malaria parasites have been developed, and these were used to screen millions of compounds. This effort, as well as improving older chemical scaffolds and optimising compounds against both known and new drug targets has resulted in the discovery of exciting new pipeline drug candidates that are now being evaluated in a number of clinical trials. In addition, the pitfalls and opportunities from this experience has led to a better definition of the optimal target compound and product profiles for new antimalarials, including medicines that treat uncomplicated or severe malaria, provide chemoprevention, or stop disease transmission, covering all stages of the parasite. An important decision element is how to combine these new molecules with existing ones in today's dynamic resistance landscape.
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Affiliation(s)
| | - Timothy Nc Wells
- Medicines for Malaria Venture, 20 route de Pre-Bois, 1215 Geneva, Switzerland.
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20
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Mohon AN, Menard D, Alam MS, Perera K, Pillai DR. A Novel Single-Nucleotide Polymorphism Loop Mediated Isothermal Amplification Assay for Detection of Artemisinin-Resistant Plasmodium falciparum Malaria. Open Forum Infect Dis 2018; 5:ofy011. [PMID: 29707598 PMCID: PMC5912083 DOI: 10.1093/ofid/ofy011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/08/2018] [Indexed: 01/06/2023] Open
Abstract
Background Artemisinin-resistant malaria (ARM) remains a significant threat to malaria elimination. In the Greater Mekong subregion, the prevalence of ARM in certain regions has reached greater than 90%. Artemisinin-resistant malaria is clinically identified by delayed parasite clearance and has been associated with mutations in the propeller domain of the kelch 13 gene. C580Y is the most prevalent mutation. The detection of ARM currently relies on labor-intensive and time-consuming methods such as clinical phenotyping or in vitro susceptibility testing. Methods We developed a novel single-nucleotide polymorphism loop mediated isothermal amplification (SNP-LAMP) test method for the detection of the C580Y mutation using a novel primer design strategy. Results The SNP-LAMP was 90.0% sensitive (95% confidence interval [CI], 66.9-98.3) and 91.9% specific (95% CI, 82.6-96.7) without knowledge of the parasite load and was 100% sensitive (95% CI, 79.9-100) and 97.3% specific (95% CI, 89.7-99.5) when the parasitemia was within the assay dynamic range. Tests with potential application near-to-patient such as SNP-LAMP may be deployed in low- and middle-income and developed countries. Conclusions Single-nucleotide polymorphism LAMP can serve as a surveillance tool and guide treatment algorithms for ARM in a clinically relevant time frame, prevent unnecessary use of additional drugs that may drive additional resistance, and avoid longer treatment regimens that cause toxicity for the patient.
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Affiliation(s)
- Abu Naser Mohon
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Alberta, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada
| | - Didier Menard
- Unité Biologie des Interactions Hôte-Parasite, Institut Pasteur, Paris, France
| | - Mohammad Shafiul Alam
- Parasitology Laboratory, Centre for Vaccine Sciences, International Center for Diarrheal Disease Research, Mohakhali, Bangladesh
| | - Kevin Perera
- Department of Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada.,Department of Biological Sciences, University of Calgary, Alberta, Canada
| | - Dylan R Pillai
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Alberta, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada
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21
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Plasmodium falciparum. Emerg Top Life Sci 2017; 1:517-523. [PMID: 33525841 DOI: 10.1042/etls20170099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/17/2022]
Abstract
Plasmodium falciparum is a protozoan parasite that causes the most severe form of human malaria. Five other Plasmodium species can also infect humans - P. vivax, P. malariae, P. ovale curtisi, P. ovale wallikeri and P. knowlesi - but P. falciparum is the most prevalent Plasmodium species in the African region, where 90% of all malaria occurs, and it is this species that causes the great majority of malaria deaths. These were reported by the WHO at 438 000 in 2015 from an estimated 214 million cases; importantly, however, figures for the global burden of malaria tend to have wide margins of error due to poor and inaccurate reporting. In this Perspective, features of P. falciparum that are unique among human malaria parasites are highlighted, and current issues surrounding the control and treatment of this major human pathogen are discussed.
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22
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Genetic markers of artemisinin resistance in Plasmodium spp. parasites. Emerg Top Life Sci 2017; 1:525-531. [PMID: 33525848 PMCID: PMC7288991 DOI: 10.1042/etls20170100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 12/15/2022]
Abstract
The vast majority of malaria patients worldwide are currently treated with combination therapy comprising one of the artemisinin family of drugs, characterised by rapid action and short plasma half-life, co-formulated with a longer-lasting drug from the amino aryl-alcohol or quinoline families. There is now a widely perceived threat to treatment efficacy, as reduced susceptibility to rapid artemisinin clearance in vivo has become prevalent among populations of Plasmodium falciparum in the Greater Mekong subregion since 2008. In vitro and in vivo drug selection studies, heterologous cell expression experiments and genetic epidemiology have identified many candidate markers of reduced ring-stage susceptibility to artemisinin. Certain variants of the P. falciparum pfk13 gene, which encodes a kelch domain protein implicated in the unfolded protein response, are strongly associated with slow parasite clearance by artemisinin in the Mekong subregion. However, anomalies in the epidemiological association of pfk13 variants with true treatment failure in vivo and the curious cell-cycle stage specificity of this phenotype in vitro warrant exploration in some depth. Taken together, available data suggest that the emergence of P. falciparum expressing K13 variants has not yet precipitated a public health emergency. Alternative candidate markers of artemisinin susceptibility are also described, as K13-independent treatment failure has been observed in African P. falciparum and in the rodent malaria parasite Plasmodium chabaudi.
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