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Blessborn D, Kaewkhao N, Tarning J. A high-throughput LC-MS/MS assay for piperaquine from dried blood spots: Improving malaria treatment in resource-limited settings. J Mass Spectrom Adv Clin Lab 2024; 31:19-26. [PMID: 38229676 PMCID: PMC10789632 DOI: 10.1016/j.jmsacl.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/18/2024] Open
Abstract
Background Malaria is a parasitic disease that affects many of the poorest economies, resulting in approximately 241 million clinical episodes and 627,000 deaths annually. Piperaquine, when administered with dihydroartemisinin, is an effective drug against the disease. Drug concentration measurements taken on day 7 after treatment initiation have been shown to be a good predictor of therapeutic success with piperaquine. A simple capillary blood collection technique, where blood is dried onto filter paper, is especially suitable for drug studies in remote areas or resource-limited settings or when taking samples from children, toddlers, and infants. Methods Three 3.2 mm discs were punched out from a dried blood spot (DBS) and then extracted in a 96-well plate using solid phase extraction on a fully automated liquid handling system. The analysis was performed using LC-MS/MS with a calibration range of 3 - 1000 ng/mL. Results The recovery rate was approximately 54-72 %, and the relative standard deviation was below 9 % for low, middle and high quality control levels. The LC-MS/MS quantification limit of 3 ng/mL is sensitive enough to detect piperaquine for up to 4-8 weeks after drug administration, which is crucial when evaluating recrudescence and drug resistance development. While different hematocrit levels can affect DBS drug measurements, the effect was minimal for piperaquine. Conclusion A sensitive LC-MS/MS method, in combination with fully automated extraction in a 96-well plate format, was developed and validated for the quantification of piperaquine in DBS. The assay was implemented in a bioanalytical laboratory for processing large-scale clinical trial samples.
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Affiliation(s)
- Daniel Blessborn
- 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, University of Oxford, Oxford, UK
| | - Natpapat Kaewkhao
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Joel Tarning
- 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, University of Oxford, Oxford, UK
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de Haan F, Amaratunga C, Thi VAC, Orng LH, Vonglokham M, Quang TN, Lek D, Boon WPC, Dondorp AM, Moors EHM. Strategies for deploying triple artemisinin-based combination therapy in the Greater Mekong Subregion. Malar J 2023; 22:261. [PMID: 37674172 PMCID: PMC10483751 DOI: 10.1186/s12936-023-04666-4] [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: 06/02/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND This is a qualitative study to identify implementation challenges for deploying triple artemisinin-based combination therapy (TACT) in the Greater Mekong Subregion (GMS) of Southeast Asia and to explore strategies to overcome these challenges. METHODS In-depth interviews were conducted in three countries that have repeatedly been confronted with ACT failures: Cambodia, Vietnam, and Lao PDR. Thirty-nine key stakeholders in the healthcare systems in these countries were interviewed. One participatory workshop was conducted in Cambodia, where scenarios for potential TACT deployment were discussed. RESULTS The results section is organized around four strategic themes that emerged from the data: policy support, data and evidence, logistics and operation, and downstream engagement. The study revealed that countries in the GMS currently rely on ACT to eliminate Plasmodium falciparum malaria by 2025. TACT is, however, considered to be a useful backup strategy in case of future treatment failures and to prevent the re-establishment of malaria. The study showed that a major challenge ahead is to engage decision makers and healthcare providers into deploying TACT, given the low case incidence of falciparum malaria in the GMS. Interview respondents were also skeptical whether healthcare providers would be willing to engage in new therapies for a disease they hardly encounter anymore. Hence, elaborate information dissemination strategies were considered appropriate and these strategies should especially target village malaria workers. Respondents proposed several regulatory and programmatic strategies to anticipate the formation of TACT markets in the GMS. These strategies include early dossier submission to streamline regulatory procedures, early stakeholder engagement strategies to shorten implementation timelines, and inclusion of TACT as second-line therapy to accelerate their introduction in case they are urgently needed. CONCLUSIONS This paper presents a qualitative study to identify implementation challenges for deploying TACT in the GMS and to explore strategies to overcome these challenges. The findings could benefit researchers and decision makers in strategizing towards potential future deployment of TACT in the GMS to combat artemisinin and partner drug resistance.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands.
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Van Anh Cao Thi
- The University of North Carolina Project in Vietnam, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Long Heng Orng
- Mahidol Oxford Tropical Medicine Research Unit, Epidemiology Department, Mahidol University, Bangkok, Thailand
| | - Manithong Vonglokham
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane Capital, Lao PDR
| | - Thieu Nguyen Quang
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Dysoley Lek
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ellen H M Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
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de Haan F, Boon WPC, Amaratunga C, Dondorp AM. Expert perspectives on the introduction of Triple Artemisinin-based Combination Therapies (TACTs) in Southeast Asia: a Delphi study. BMC Public Health 2022; 22:864. [PMID: 35490212 PMCID: PMC9055751 DOI: 10.1186/s12889-022-13212-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Triple Artemisinin-based Combination Therapies (TACTs) are being developed as a response to artemisinin and partner drug resistance in Southeast Asia. However, the desirability, timing and practical feasibility of introducing TACTs in Southeast Asia is subject to debate. This study systematically assesses perspectives of malaria experts towards the introduction of TACTs as first-line treatment for uncomplicated falciparum malaria in Southeast Asia. METHODS A two-round Delphi study was conducted. In the first round, 53 malaria experts answered open-ended questions on what they consider the most important advantages, disadvantages, and implementation barriers for introducing TACTs in Southeast Asia. In the second round, the expert panel rated the relevance of each statement on a 5-point Likert scale. RESULTS Malaria experts identified 15 advantages, 15 disadvantages and 13 implementation barriers for introducing TACTs in Southeast Asia in the first round of data collection. In the second round, consensus was reached on 13 advantages (8 perceived as relevant, 5 as not-relevant), 12 disadvantages (10 relevant, 2 not-relevant), and 13 implementation barriers (all relevant). Advantages attributed highest relevance related to the clinical and epidemiological rationale of introducing TACTs. Disadvantages attributed highest relevance related to increased side-effects, unavailability of fixed-dose TACTs, and potential cost increases. Implementation barriers attributed highest relevance related to obtaining timely regulatory approval, timely availability of fixed-dose TACTs, and generating global policy support for introducing TACTs. CONCLUSIONS The study provides a structured oversight of malaria experts' perceptions on the major advantages, disadvantages and implementation challenges for introducing TACTs in Southeast Asia, over current practices of rotating ACTs when treatment failure is observed. The findings can benefit strategic decision making in the battle against drug-resistant malaria.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands.
| | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Ratchathewi DistrictBangkok, 10400, Thailand
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Ratchathewi DistrictBangkok, 10400, Thailand
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Perehudoff K, Durán C, Demchenko I, Mazzanti V, Parwani P, Suleman F, de Ruijter A. Impact of the European Union on access to medicines in low- and middle-income countries: A scoping review. THE LANCET REGIONAL HEALTH. EUROPE 2021; 9:100219. [PMID: 34693391 PMCID: PMC8513155 DOI: 10.1016/j.lanepe.2021.100219] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This Scoping Review synthesises evidence of the impacts of European Union (EU) law, regulation, and policy on access to medicines in in non-EU low- and middle-income countries (LMICs), and the mechanisms and nature of those impacts. We searched eight scholarly databases and grey literature published between 1995-2021 in four languages. The EU exerts global influence on pharmaceuticals in LMICs in three ways: explicit agreements between EU-LMICs (ex. accession, trade, and economic agreements); LMICs' reliance on EU internal regulation, standards, or methods (ex. market authorisation); 'soft' forms of EU influence (ex. research funding, capacity building). This study illustrates that EU policy makers adopt measures with the potential to influence medicines in LMICs despite limited evidence of their positive and/or negative impact(s). The EU's fragmented internal and external actions in fields related to pharmaceuticals reveal the need for principles for global equitable access to medicines to guide EU policy.
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Affiliation(s)
- Katrina Perehudoff
- Law Centre for Health & Life, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP Amsterdam, Netherlands
- Amsterdam Centre for European Law and Governance, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
- WHO Collaborating Centre for Governance, Accountability, and Transparency in the Pharmaceutical Sector, University of Toronto, Canada
- Medicines Law & Policy, Amsterdam, the Netherlands
- Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Carlos Durán
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands
| | - Ivan Demchenko
- Department of Forensic Medicine and Medical Law, Bogomolets National Medical University, st. Mechnikova, 5, Kyiv, 01133, Ukraine
| | - Valentina Mazzanti
- Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Pramiti Parwani
- Law Centre for Health & Life, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP Amsterdam, Netherlands
- Amsterdam Centre for European Law and Governance, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
| | - Fatima Suleman
- Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Campus Westville, Durban, 4041, South Africa
- WHO Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice, University of KwaZulu-Natal, Campus Westville, Durban, 4041, South Africa
| | - Anniek de Ruijter
- Law Centre for Health & Life, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP Amsterdam, Netherlands
- Amsterdam Centre for European Law and Governance, Amsterdam Law School, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV Amsterdam, Netherlands
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de Haan F, Moors EH, Dondorp AM, Boon WP. Market Formation in a Global Health Transition. ENVIRONMENTAL INNOVATION AND SOCIETAL TRANSITIONS 2021; 40:40-59. [PMID: 35106274 PMCID: PMC7612298 DOI: 10.1016/j.eist.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transition studies have started to focus on market formation in innovation systems. This article investigates market formation in a global health transition that was instigated by drug-resistant malaria. We explore how markets for Artemisinin-based Combination Therapies (ACT) in the Greater Mekong Subregion (GMS) were formed at multiple geographical scales and locations. The study reveals the role of public institutes, academia and partnerships in early innovation system development. It demonstrates how transnational organizations created a supportive global landscape for ACT development and deployment. It then reveals how these advancements led to the formation of public-sector and private-sector ACT markets in the GMS. We illustrate how market formation activities took place on global, national and local scales and how structural couplings enabled the functioning of this global innovation system. The lessons learned are particularly relevant now that drug-resistant malaria has once more emerged in the GMS, urgently calling for new therapies and associated end-user markets.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands
- Corresponding author. (F. de Haan), (E.H.M. Moors), (A.M. Dondorp), (W.P.C. Boon)
| | - Ellen H.M. Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 73170 Bangkok, Thailand
| | - Wouter P.C. Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 73170 Bangkok, Thailand
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Abstract
The last two decades have seen a surge in antimalarial drug development with product development partnerships taking a leading role. Resistance of Plasmodium falciparum to the artemisinin derivatives, piperaquine and mefloquine in Southeast Asia means new antimalarials are needed with some urgency. There are at least 13 agents in clinical development. Most of these are blood schizonticides for the treatment of uncomplicated falciparum malaria, under evaluation either singly or as part of two-drug combinations. Leading candidates progressing through the pipeline are artefenomel-ferroquine and lumefantrine-KAF156, both in Phase 2b. Treatment of severe malaria continues to rely on two parenteral drugs with ancient forebears: artesunate and quinine, with sevuparin being evaluated as an adjuvant therapy. Tafenoquine is under review by stringent regulatory authorities for approval as a single-dose treatment for Plasmodium vivax relapse prevention. This represents an advance over standard 14-day primaquine regimens; however, the risk of acute haemolytic anaemia in patients with glucose-6-phosphate dehydrogenase deficiency remains. For disease prevention, several of the newer agents show potential but are unlikely to be recommended for use in the main target groups of pregnant women and young children for some years. Latest predictions are that the malaria burden will continue to be high in the coming decades. This fact, coupled with the repeated loss of antimalarials to resistance, indicates that new antimalarials will be needed for years to come. Failure of the artemisinin-based combinations in Southeast Asia has stimulated a reappraisal of current approaches to combination therapy for malaria with incorporation of three or more drugs in a single treatment under consideration.
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Affiliation(s)
- Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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Fernando D, Wijeyaratne P, Wickremasinghe R, Abeyasinghe RR, Galappaththy GNL, Wickremasinghe R, Hapugoda M, Abeywickrema WA, Rodrigo C. Use of a public-private partnership in malaria elimination efforts in Sri Lanka; a case study. BMC Health Serv Res 2018; 18:202. [PMID: 29566691 PMCID: PMC5865373 DOI: 10.1186/s12913-018-3008-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 03/15/2018] [Indexed: 12/24/2022] Open
Abstract
Background In special circumstances, establishing public private partnerships for malaria elimination may achieve targets faster than the state sector acting by itself. Following the end of the separatist war in Sri Lanka in 2009, the Anti Malaria Campaign (AMC) of Sri Lanka intensified malaria surveillance jointly with a private sector partner, Tropical and Environmental Diseases and Health Associates Private Limited (TEDHA) with a view to achieving malaria elimination targets by 2014. Methods This is a case study on how public private partnerships can be effectively utilized to achieve malaria elimination goals. TEDHA established 50 Malaria Diagnostic Laboratories and 17 entomology surveillance sentinel sites in consultation with the AMC in areas difficult to access by government officials (five districts in two provinces affected by war). Results TEDHA screened 994,448 individuals for malaria, of which 243,867 were screened at mobile malaria clinics as compared to 1,102,054 screened by the AMC. Nine malaria positives were diagnosed by TEDHA, while the AMC diagnosed 103 malaria cases in the same districts in parallel. Over 13,000 entomological activity days were completed. Relevant information was shared with AMC and the data recorded in the health information system. Conclusions A successful public-private partnership model for malaria elimination was initiated at a time when the health system was in disarray in war ravaged areas of Sri Lanka. This ensured a high annual blood examination rate and screening of vulnerable people in receptive areas. These were important for certification of malaria-free status which Sri Lanka eventually received in 2016.
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Affiliation(s)
- Deepika Fernando
- Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Pandu Wijeyaratne
- Tropical and Environmental Diseases and Health Associates, No. 3 Elibank Road, Colombo, Sri Lanka
| | - Rajitha Wickremasinghe
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | | | - Renu Wickremasinghe
- Department of Parasitology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - M Hapugoda
- Department of Parasitology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - W A Abeywickrema
- Department of Parasitology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Chaturaka Rodrigo
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Olafuyi O, Coleman M, Badhan RK. The application of physiologically based pharmacokinetic modelling to assess the impact of antiretroviral-mediated drug-drug interactions on piperaquine antimalarial therapy during pregnancy. Biopharm Drug Dispos 2017; 38:464-478. [DOI: 10.1002/bdd.2087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/22/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Olusola Olafuyi
- Aston Healthy Research Group, Aston Pharmacy School; Aston University; Birmingham B4 7ET UK
| | - Michael Coleman
- Aston Pharmacy School; Aston University; Birmingham B4 7ET UK
| | - Raj K.S. Badhan
- Aston Healthy Research Group, Aston Pharmacy School; Aston University; Birmingham B4 7ET UK
- Aston Pharmacy School; Aston University; Birmingham B4 7ET UK
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Kabanywanyi AM, Baiden R, Ali AM, Mahende MK, Ogutu BR, Oduro A, Tinto H, Gyapong M, Sie A, Sevene E, Macete E, Owusu-Agyei S, Adjei A, Compaoré G, Valea I, Osei I, Yawson A, Adjuik M, Akparibo R, Kakolwa MA, Abdulla S, Binka F. Multi-Country Evaluation of Safety of Dihydroartemisinin/Piperaquine Post-Licensure in African Public Hospitals with Electrocardiograms. PLoS One 2016; 11:e0164851. [PMID: 27764178 PMCID: PMC5072600 DOI: 10.1371/journal.pone.0164851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/28/2016] [Indexed: 01/06/2023] Open
Abstract
The antimalarial drug piperaquine is associated with delayed ventricular depolarization, causing prolonged QT interval (time taken for ventricular de-polarisation and re-polarisation). There is a lack of safety data regarding dihydroartemisinin/piperaquine (DHA/PPQ) for the treatment of uncomplicated malaria, which has limited its use. We created a platform where electrocardiograms (ECG) were performed in public hospitals for the safety assessment of DHA/PPQ, at baseline before the use of dihydroartemisinin/piperaquine (Eurartesim®), and on day 3 (before and after administration of the final dose) and day 7 post-administration. Laboratory analyses included haematology and clinical chemistry. The main objective of the ECG assessment in this study was to evaluate the effect of administration of DHA/PPQ on QTc intervals and the association of QTc intervals with changes in blood biochemistry, full and differential blood count over time after the DHA/PPQ administration. A total of 1315 patients gave consent and were enrolled of which 1147 (87%) had complete information for analyses. Of the enrolled patients 488 (42%), 323 (28%), 213 (19%) and 123 (11%) were from Ghana, Burkina Faso, Tanzania and Mozambique, respectively. Median (lower—upper quartile) age was 8 (5–14) years and a quarter of the patients were children under five years of age (n = 287). Changes in blood biochemistry, full and differential blood count were temporal which remained within clinical thresholds and did not require any intervention. The mean QTcF values were significantly higher than on day 1 when measured on day 3 before and after administration of the treatment as well as on day 7, four days after completion of treatment (12, 22 and 4 higher, p < 0.001). In all age groups the values of QT, QTcF and QTcB were highest on day 3 after drug intake. The mean extreme QTcF prolongation from baseline was lowest on day 3 before drug intake (33 ms, SD = 19) and highest on day 3 after the last dose (60 ms, SD = 31). There were 79 (7%) events of extreme mean QTcF prolongation which were not clinically significant. Nearly a half of them (n = 37) were grade 3 and mainly among males (33/37). Patients in Burkina Faso, Mozambique and Tanzania had significantly lower mean QTcF than patients in Ghana by an average of 3, 4 and 11 ms, respectively. We found no evidence that Eurartesim® administered in therapeutic doses in patients with uncomplicated malaria and no predisposing cardiac conditions in Africa was associated with adverse clinically significant QTc prolongation.
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Affiliation(s)
| | | | - Ali M. Ali
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | | | | | | | - Ali Sie
- Nouna Health Research Centre, Nouna, Burkina Faso
| | - Esperanca Sevene
- Centro de Investigaçãoem Saúde de Manhiça(CISM), Manhiça, Mozambique
| | - Eusebio Macete
- Centro de Investigaçãoem Saúde de Manhiça(CISM), Manhiça, Mozambique
| | | | - Alex Adjei
- Dodowa Health Research Centre, Dodowa, Ghana
| | | | | | - Isaac Osei
- Navrongo Health Research Centre, Navrongo, Ghana
| | - Abena Yawson
- Kintampo Health Research Centre, Kintampo, Ghana
| | | | | | | | | | - Fred Binka
- University for Health and Allied Sciences, Ho, Ghana
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Novotny J, Singh A, Dysoley L, Sovannaroth S, Rekol H. Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys. Malar J 2016; 15:194. [PMID: 27059952 PMCID: PMC4826540 DOI: 10.1186/s12936-016-1200-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/01/2016] [Indexed: 01/11/2023] Open
Abstract
Background For over a decade, Cambodia has implemented a number of policies and innovative strategies to increase access to quality malaria case management services and address the drivers of multi-drug resistance. This paper utilizes outlet survey trend data collected by the ACTwatch project to demonstrate how changes in Cambodian policy and strategies have led to shifts in anti-malarial markets. Methods Anti-malarial ACTwatch outlet surveys were conducted in Cambodia in 2009 (June–July), 2011 (June–August) and 2013 (September–October). A census of all outlets with the potential to sell or distribute anti-malarials was conducted within a nationally representative sample of communes. Drug information, sales/distribution in the previous week, and retail price were collected for each anti-malarial in stock. Information on availability of malaria blood testing was also collected. Results A total of 7833 outlets were enumerated in 2009, 18,584 in 2011, and 16,153 in 2013. The percentage of public health facilities with at least one anti-malarial in stock on the day of the survey increased between 2009 (65.8 %) and 2011 (90.0 %) and remained high in 2013 (82.0 %). Similar trends were found for village malaria workers (VMW). Overall, private sector availability of anti-malarials declined over time and varied by outlet type. By 2013 most anti-malarial stocking public health facilities (81.5 %), VMW (95.4 %), private for-profit health facilities (64.8 %), and pharmacies (71.9 %) had the countries first-line artemisinin-based combination therapy (ACT) treatment in stock. In 2013, 60 % of anti-malarials were delivered through the private sector, 40 % through the public sector, and the most common anti-malarial to be sold or distributed was the first-line ACT, comprising 62.8 % of the national market share. Oral artemisinin monotherapy, which had accounted for 6 % of total anti-malarial market share in 2009, was no longer reportedly sold/distributed in 2013. Malaria blood testing availability remained high over time among public facilities and VMW, with availability over 90 % in 2011 and 2013. Moderate availability was observed in the private sector. Conclusions Continued implementation of successful public and private sector strategies in support of evolving malaria drug treatment policies will be important to protect the efficacy of anti-malarial medicines and ultimately facilitate malaria elimination in Cambodia by 2025. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1200-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Joe Novotny
- Clinton Health Access Initiative, #7B, Str. 81 and corner Str. 109, Sangkat Boeung Raing, Khan Don Penh, Phnom Penh, Cambodia
| | - Amandeep Singh
- Clinton Health Access Initiative, #7B, Str. 81 and corner Str. 109, Sangkat Boeung Raing, Khan Don Penh, Phnom Penh, Cambodia
| | - Lek Dysoley
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia.,School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Siv Sovannaroth
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia
| | - Huy Rekol
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia
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Paloque L, Ramadani AP, Mercereau-Puijalon O, Augereau JM, Benoit-Vical F. Plasmodium falciparum: multifaceted resistance to artemisinins. Malar J 2016; 15:149. [PMID: 26955948 PMCID: PMC4784301 DOI: 10.1186/s12936-016-1206-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 03/01/2016] [Indexed: 11/18/2022] Open
Abstract
Plasmodium falciparum resistance to artemisinins, the most potent and fastest acting anti-malarials, threatens malaria elimination strategies. Artemisinin resistance is due to mutation of the PfK13 propeller domain and involves an unconventional mechanism based on a quiescence state leading to parasite recrudescence as soon as drug pressure is removed. The enhanced P. falciparum quiescence capacity of artemisinin-resistant parasites results from an increased ability to manage oxidative damage and an altered cell cycle gene regulation within a complex network involving the unfolded protein response, the PI3K/PI3P/AKT pathway, the PfPK4/eIF2α cascade and yet unidentified transcription factor(s), with minimal energetic requirements and fatty acid metabolism maintained in the mitochondrion and apicoplast. The detailed study of these mechanisms offers a way forward for identifying future intervention targets to fend off established artemisinin resistance.
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Affiliation(s)
- Lucie Paloque
- CNRS, LCC (Laboratoire de Chimie de Coordination) UPR8241, 205 route de Narbonne, BP 44099, 31077, Toulouse Cedex 4, France. .,Université de Toulouse, UPS, INPT, 31077, Toulouse Cedex 4, France.
| | - Arba P Ramadani
- CNRS, LCC (Laboratoire de Chimie de Coordination) UPR8241, 205 route de Narbonne, BP 44099, 31077, Toulouse Cedex 4, France. .,Université de Toulouse, UPS, INPT, 31077, Toulouse Cedex 4, France. .,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | | | - Jean-Michel Augereau
- CNRS, LCC (Laboratoire de Chimie de Coordination) UPR8241, 205 route de Narbonne, BP 44099, 31077, Toulouse Cedex 4, France. .,Université de Toulouse, UPS, INPT, 31077, Toulouse Cedex 4, France.
| | - Françoise Benoit-Vical
- CNRS, LCC (Laboratoire de Chimie de Coordination) UPR8241, 205 route de Narbonne, BP 44099, 31077, Toulouse Cedex 4, France. .,Université de Toulouse, UPS, INPT, 31077, Toulouse Cedex 4, France.
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12
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Pfeil J, Borrmann S, Bassat Q, Mulenga M, Talisuna A, Tozan Y. An Economic Evaluation of the Posttreatment Prophylactic Effect of Dihydroartemisinin-Piperaquine Versus Artemether-Lumefantrine for First-Line Treatment of Plasmodium falciparum Malaria Across Different Transmission Settings in Africa. Am J Trop Med Hyg 2015; 93:961-6. [PMID: 26240155 DOI: 10.4269/ajtmh.15-0162] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/24/2015] [Indexed: 01/17/2023] Open
Abstract
Malaria disproportionately affects young children. Clinical trials in African children showed that dihydroartemisinin-piperaquine (DP) is an effective antimalarial and has a longer posttreatment prophylactic (PTP) effect against reinfections than other artemisinin-based combination therapies, including artemether-lumefantrine (AL). Using a previously developed Markov model and individual patient data from a multicenter African drug efficacy trial, we assessed the economic value of the PTP effect of DP versus AL in pediatric malaria patients from health-care provider's perspective in low-to-moderate and moderate-to-high transmission settings under different drug co-payment scenarios. In low-to-moderate transmission settings, first-line treatment with DP was highly cost-effective with an incremental cost-effectiveness ratio of US$5 (95% confidence interval [CI] = -76 to 196) per disability-adjusted life year (DALY) averted. In moderate-to-high transmission settings, DP first-line treatment led to a mean cost saving of US$1.09 (95% CI = -0.88 to 3.85) and averted 0.05 (95% CI = -0.08 to 0.22) DALYs per child per year. Our results suggested that DP might be superior to AL for first-line treatment of uncomplicated childhood malaria across a range of transmission settings in Africa.
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Affiliation(s)
- Johannes Pfeil
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Steffen Borrmann
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Quique Bassat
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Modest Mulenga
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ambrose Talisuna
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Yesim Tozan
- Parasitology Unit, Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany; General Pediatrics Unit, Center for Childhood and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany; German Centre for Infectious Diseases (DZIF), University of Tübingen, Tübingen, Germany; ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Tropical Diseases Research Centre, Ndola, Zambia; Department of Public Health Research, University of Oxford-KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya; Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; College of Global Public Health, New York University, New York, New York; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
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13
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Abstract
Despite substantial scientific progress over the past two decades, malaria remains a worldwide burden that causes hundreds of thousands of deaths every year. New, affordable and safe drugs are required to overcome increasing resistance against artemisinin-based treatments, treat vulnerable populations, interrupt the parasite life cycle by blocking transmission to the vectors, prevent infection and target malaria species that transiently remain dormant in the liver. In this Review, we discuss how the antimalarial drug discovery pipeline has changed over the past 10 years, grouped by the various target compound or product profiles, to assess progress and gaps, and to recommend priorities.
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14
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Baiden R, Oduro A, Halidou T, Gyapong M, Sie A, Macete E, Abdulla S, Owusu-Agyei S, Mulokozi A, Adjei A, Sevene E, Compaoré G, Valea I, Osei I, Yawson A, Adjuik M, Akparibo R, Ogutu B, Upunda GL, Smith P, Binka F. Prospective observational study to evaluate the clinical safety of the fixed-dose artemisinin-based combination Eurartesim® (dihydroartemisinin/piperaquine), in public health facilities in Burkina Faso, Mozambique, Ghana, and Tanzania. Malar J 2015; 14:160. [PMID: 25885858 PMCID: PMC4405867 DOI: 10.1186/s12936-015-0664-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/24/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The World Health Organization recommends artemisinin-based combination (ACT) for the treatment of uncomplicated malaria. Post-licensure safety data on newly registered ACT is critical for evaluating their risk/benefit profile in malaria endemic countries. The clinical safety of the newly registered combination, Eurartesim®, following its introduction into the public health system in four African countries was assessed. METHODS This was a prospective, observational, open-label, non-comparative, longitudinal, multi-centre study using cohort event monitoring. Patients with confirmed malaria had their first dose observed and instructed on how to take the second and the third doses at home. Patients were contacted on day 5 ± 2 to assess adherence and adverse events (AEs). Spontaneous reporting of AEs was continued till day 28. A nested cohort who completed full treatment course had repeated electrocardiogram (ECG) measurements to assess effect on QTc interval. RESULTS A total of 10,925 uncomplicated malaria patients were treated with Eurartesim®. Most patients,95% (10,359/10,925), did not report any adverse event following at least one dose of Eurartesim®. A total of 797 adverse events were reported. The most frequently reported, by system organ classification, were infections and infestations (3. 24%) and gastrointestinal disorders (1. 37%). In the nested cohort, no patient had QTcF > 500 ms prior to day 3 pre-dose 3. Three patients had QTcF > 500 ms (509 ms, 501 ms, 538 ms) three to four hours after intake of the last dose. All the QTcF values in the three patients had returned to <500 ms at the next scheduled ECG on day 7 (470 ms, 442 ms, 411 ms). On day 3 pre- and post-dose 3, 70 and 89 patients, respectively, had a QTcF increase of ≥ 60 ms compared to their baseline, but returned to nearly baseline values on day 7. CONCLUSION Eurartesim® single course treatment for uncomplicated falciparum malaria is well-tolerated. QT interval prolongation above 500 ms may occur at a rate of three per 1,002 patients after the third dose with no association of any clinical symptoms. QT interval prolongation above 60 ms was detected in less than 10% of the patients without any clinical abnormalities.
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Affiliation(s)
| | | | - Tinto Halidou
- Nanoro Health Research Centre, Nanoro, Burkina Faso.
| | | | - Ali Sie
- Nouna Health Research Centre, Nouna, Burkina Faso.
| | - Eusebio Macete
- Centro de InvestigaçãoemSaúde de Manhiça, CISM, Manhiça, Mozambique.
| | | | | | | | - Alex Adjei
- Dodowa Health Research Centre, Dodowa, Ghana.
| | - Esperanca Sevene
- Centro de InvestigaçãoemSaúde de Manhiça, CISM, Manhiça, Mozambique.
| | | | | | - Isaac Osei
- Navrongo Health Research Centre, Navrongo, Ghana.
| | - Abena Yawson
- Kintampo Health Research Centre, Kintampo, Ghana.
| | | | | | | | | | - Peter Smith
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Fred Binka
- INDEPTH Network, Accra, Ghana. .,University for Health and Allied Sciences, Ho, Ghana.
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15
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Bellgard MI, Sleeman MW, Guerrero FD, Fletcher S, Baynam G, Goldblatt J, Rubinstein Y, Bell C, Groft S, Barrero R, Bittles AH, Wilton SD, Mason CE, Weeramanthri T. Rare Disease Research Roadmap: Navigating the bioinformatics and translational challenges for improved patient health outcomes. HEALTH POLICY AND TECHNOLOGY 2014. [DOI: 10.1016/j.hlpt.2014.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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16
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Mori AT, Ngalesoni F, Norheim OF, Robberstad B. Cost-effectiveness of dihydroartemisinin-piperaquine compared with artemether-lumefantrine for treating uncomplicated malaria in children at a district hospital in Tanzania. Malar J 2014; 13:363. [PMID: 25223864 PMCID: PMC4171550 DOI: 10.1186/1475-2875-13-363] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 09/12/2014] [Indexed: 01/01/2023] Open
Abstract
Background Dihydroartemisinin-piperaquine (DhP) is highly recommended for the treatment of uncomplicated malaria. This study aims to compare the costs, health benefits and cost-effectiveness of DhP and artemether-lumefantrine (AL) alongside “do-nothing” as a baseline comparator in order to consider the appropriateness of DhP as a first-line anti-malarial drug for children in Tanzania. Methods A cost-effectiveness analysis was performed using a Markov decision model, from a provider’s perspective. The study used cost data from Tanzania and secondary effectiveness data from a review of articles from sub-Saharan Africa. Probabilistic sensitivity analysis was used to incorporate uncertainties in the model parameters. In addition, sensitivity analyses were used to test plausible variations of key parameters and the key assumptions were tested in scenario analyses. Results The model predicts that DhP is more cost-effective than AL, with an incremental cost-effectiveness ratio (ICER) of US$ 12.40 per DALY averted. This result relies on the assumption that compliance to treatment with DhP is higher than that with AL due to its relatively simple once-a-day dosage regimen. When compliance was assumed to be identical for the two drugs, AL was more cost-effective than DhP with an ICER of US$ 12.54 per DALY averted. DhP is, however, slightly more likely to be cost-effective compared to a willingness-to-pay threshold of US$ 150 per DALY averted. Conclusion Dihydroartemisinin-piperaquine is a very cost-effective anti-malarial drug. The findings support its use as an alternative first-line drug for treatment of uncomplicated malaria in children in Tanzania and other sub-Saharan African countries with similar healthcare infrastructures and epidemiology of malaria. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-363) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amani T Mori
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, P,O, Box 7804, 5020 Bergen, Norway.
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17
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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014; 9:e95681. [PMID: 24748395 PMCID: PMC3991722 DOI: 10.1371/journal.pone.0095681] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/31/2014] [Indexed: 12/31/2022] Open
Abstract
Background Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. Methods We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. Results First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006–0.07) and 0.001 deaths (95% CI: 0.00–0.002) and saved $0.96 (95% CI: 0.33–2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. Conclusions DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
- * E-mail:
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18
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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014. [PMID: 24748395 DOI: 10.1371/journal.pone.0095681.ecollection] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. METHODS We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. RESULTS First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006-0.07) and 0.001 deaths (95% CI: 0.00-0.002) and saved $0.96 (95% CI: 0.33-2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. CONCLUSIONS DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany; German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
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19
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Hrycyna CA, Summers RL, Lehane AM, Pires MM, Namanja H, Bohn K, Kuriakose J, Ferdig M, Henrich PP, Fidock DA, Kirk K, Chmielewski J, Martin RE. Quinine dimers are potent inhibitors of the Plasmodium falciparum chloroquine resistance transporter and are active against quinoline-resistant P. falciparum. ACS Chem Biol 2014; 9:722-30. [PMID: 24369685 DOI: 10.1021/cb4008953] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Chloroquine (CQ) resistance in the human malaria parasite Plasmodium falciparum is primarily conferred by mutations in the "chloroquine resistance transporter" (PfCRT). The resistance-conferring form of PfCRT (PfCRT(CQR)) mediates CQ resistance by effluxing the drug from the parasite's digestive vacuole, the acidic compartment in which CQ exerts its antiplasmodial effect. PfCRT(CQR) can also decrease the parasite's susceptibility to other quinoline drugs, including the current antimalarials quinine and amodiaquine. Here we describe interactions between PfCRT(CQR) and a series of dimeric quinine molecules using a Xenopus laevis oocyte system for the heterologous expression of PfCRT and using an assay that detects the drug-associated efflux of H(+) ions from the digestive vacuole in parasites that harbor different forms of PfCRT. The antiplasmodial activities of dimers 1 and 6 were also examined in vitro (against drug-sensitive and drug-resistant strains of P. falciparum) and in vivo (against drug-sensitive P. berghei). Our data reveal that the quinine dimers are the most potent inhibitors of PfCRT(CQR) reported to date. Furthermore, the lead compounds (1 and 6) were not effluxed by PfCRT(CQR) from the digestive vacuole but instead accumulated to very high levels within this organelle. Both 1 and 6 exhibited in vitro antiplasmodial activities that were inversely correlated with CQ. Moreover, the additional parasiticidal effect exerted by 1 and 6 in the drug-resistant parasites was attributable, at least in part, to their ability to inhibit PfCRT(CQR). This highlights the potential for devising new antimalarial therapies that exploit inherent weaknesses in a key resistance mechanism of P. falciparum.
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Affiliation(s)
- Christine A. Hrycyna
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Robert L. Summers
- Research
School of Biology, The Australian National University, Canberra, Australian Capital Territory 0200, Australia
| | - Adele M. Lehane
- Research
School of Biology, The Australian National University, Canberra, Australian Capital Territory 0200, Australia
| | - Marcos M. Pires
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Hilda Namanja
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Kelsey Bohn
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Jerrin Kuriakose
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Michael Ferdig
- Department
of Biological Sciences, University of Notre Dame, Notre Dame, Indiana 46556, United States
| | - Philipp P. Henrich
- Department
of Microbiology and Immunology, Columbia University, New York, New York 10027, United States
| | - David A. Fidock
- Department
of Microbiology and Immunology, Columbia University, New York, New York 10027, United States
- Division
of Infectious Diseases, Department of Medicine, Columbia University, New York, New York 10027, United States
| | - Kiaran Kirk
- Research
School of Biology, The Australian National University, Canberra, Australian Capital Territory 0200, Australia
| | - Jean Chmielewski
- Department
of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Rowena E. Martin
- Research
School of Biology, The Australian National University, Canberra, Australian Capital Territory 0200, Australia
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