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Mansoor R, Commons RJ, Douglas NM, Abuaku B, Achan J, Adam I, Adjei GO, Adjuik M, Alemayehu BH, Allan R, Allen EN, Anvikar AR, Arinaitwe E, Ashley EA, Ashurst H, Asih PBS, Bakyaita N, Barennes H, Barnes KI, Basco L, Bassat Q, Baudin E, Bell DJ, Bethell D, Bjorkman A, Boulton C, Bousema T, Brasseur P, Bukirwa H, Burrow R, Carrara VI, Cot M, D’Alessandro U, Das D, Das S, Davis TME, Desai M, Djimde AA, Dondorp AM, Dorsey G, Drakeley CJ, Duparc S, Espié E, Etard JF, Falade C, Faucher JF, Filler S, Fogg C, Fukuda M, Gaye O, Genton B, Ghulam Rahim A, Gilayeneh J, Gonzalez R, Grais RF, Grandesso F, Greenwood B, Grivoyannis A, Hatz C, Hodel EM, Humphreys GS, Hwang J, Ishengoma D, Juma E, Kachur SP, Kager PA, Kamugisha E, Kamya MR, Karema C, Kayentao K, Kazienga A, Kiechel JR, Kofoed PE, Koram K, Kremsner PG, Lalloo DG, Laman M, Lee SJ, Lell B, Maiga AW, Mårtensson A, Mayxay M, Mbacham W, McGready R, Menan H, Ménard D, Mockenhaupt F, Moore BR, Müller O, Nahum A, Ndiaye JL, Newton PN, Ngasala BE, Nikiema F, Nji AM, Noedl H, Nosten F, Ogutu BR, Ojurongbe O, Osorio L, Ouédraogo JB, Owusu-Agyei S, Pareek A, Penali LK, Piola P, Plucinski M, Premji Z, Ramharter M, Richmond CL, Rombo L, Roper C, Rosenthal PJ, Salman S, Same-Ekobo A, Sibley C, Sirima SB, Smithuis FM, Somé FA, Staedke SG, Starzengruber P, Strub-Wourgaft N, Sutanto I, Swarthout TD, Syafruddin D, Talisuna AO, Taylor WR, Temu EA, Thwing JI, Tinto H, Tjitra E, Touré OA, Tran TH, Ursing J, Valea I, Valentini G, van Vugt M, von Seidlein L, Ward SA, Were V, White NJ, Woodrow CJ, Yavo W, Yeka A, Zongo I, Simpson JA, Guerin PJ, Stepniewska K, Price RN. Haematological consequences of acute uncomplicated falciparum malaria: a WorldWide Antimalarial Resistance Network pooled analysis of individual patient data. BMC Med 2022; 20:85. [PMID: 35249546 PMCID: PMC8900374 DOI: 10.1186/s12916-022-02265-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/18/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Plasmodium falciparum malaria is associated with anaemia-related morbidity, attributable to host, parasite and drug factors. We quantified the haematological response following treatment of uncomplicated P. falciparum malaria to identify the factors associated with malarial anaemia. METHODS Individual patient data from eligible antimalarial efficacy studies of uncomplicated P. falciparum malaria, available through the WorldWide Antimalarial Resistance Network data repository prior to August 2015, were pooled using standardised methodology. The haematological response over time was quantified using a multivariable linear mixed effects model with nonlinear terms for time, and the model was then used to estimate the mean haemoglobin at day of nadir and day 7. Multivariable logistic regression quantified risk factors for moderately severe anaemia (haemoglobin < 7 g/dL) at day 0, day 3 and day 7 as well as a fractional fall ≥ 25% at day 3 and day 7. RESULTS A total of 70,226 patients, recruited into 200 studies between 1991 and 2013, were included in the analysis: 50,859 (72.4%) enrolled in Africa, 18,451 (26.3%) in Asia and 916 (1.3%) in South America. The median haemoglobin concentration at presentation was 9.9 g/dL (range 5.0-19.7 g/dL) in Africa, 11.6 g/dL (range 5.0-20.0 g/dL) in Asia and 12.3 g/dL (range 6.9-17.9 g/dL) in South America. Moderately severe anaemia (Hb < 7g/dl) was present in 8.4% (4284/50,859) of patients from Africa, 3.3% (606/18,451) from Asia and 0.1% (1/916) from South America. The nadir haemoglobin occurred on day 2 post treatment with a mean fall from baseline of 0.57 g/dL in Africa and 1.13 g/dL in Asia. Independent risk factors for moderately severe anaemia on day 7, in both Africa and Asia, included moderately severe anaemia at baseline (adjusted odds ratio (AOR) = 16.10 and AOR = 23.00, respectively), young age (age < 1 compared to ≥ 12 years AOR = 12.81 and AOR = 6.79, respectively), high parasitaemia (AOR = 1.78 and AOR = 1.58, respectively) and delayed parasite clearance (AOR = 2.44 and AOR = 2.59, respectively). In Asia, patients treated with an artemisinin-based regimen were at significantly greater risk of moderately severe anaemia on day 7 compared to those treated with a non-artemisinin-based regimen (AOR = 2.06 [95%CI 1.39-3.05], p < 0.001). CONCLUSIONS In patients with uncomplicated P. falciparum malaria, the nadir haemoglobin occurs 2 days after starting treatment. Although artemisinin-based treatments increase the rate of parasite clearance, in Asia they are associated with a greater risk of anaemia during recovery.
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Hossain MS, Commons RJ, Douglas NM, Thriemer K, Alemayehu BH, Amaratunga C, Anvikar AR, Ashley EA, Asih PBS, Carrara VI, Lon C, D’Alessandro U, Davis TME, Dondorp AM, Edstein MD, Fairhurst RM, Ferreira MU, Hwang J, Janssens B, Karunajeewa H, Kiechel JR, Ladeia-Andrade S, Laman M, Mayxay M, McGready R, Moore BR, Mueller I, Newton PN, Thuy-Nhien NT, Noedl H, Nosten F, Phyo AP, Poespoprodjo JR, Saunders DL, Smithuis F, Spring MD, Stepniewska K, Suon S, Suputtamongkol Y, Syafruddin D, Tran HT, Valecha N, Van Herp M, Van Vugt M, White NJ, Guerin PJ, Simpson JA, Price RN. The risk of Plasmodium vivax parasitaemia after P. falciparum malaria: An individual patient data meta-analysis from the WorldWide Antimalarial Resistance Network. PLoS Med 2020; 17:e1003393. [PMID: 33211712 PMCID: PMC7676739 DOI: 10.1371/journal.pmed.1003393] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/25/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is a high risk of Plasmodium vivax parasitaemia following treatment of falciparum malaria. Our study aimed to quantify this risk and the associated determinants using an individual patient data meta-analysis in order to identify populations in which a policy of universal radical cure, combining artemisinin-based combination therapy (ACT) with a hypnozoitocidal antimalarial drug, would be beneficial. METHODS AND FINDINGS A systematic review of Medline, Embase, Web of Science, and the Cochrane Database of Systematic Reviews identified efficacy studies of uncomplicated falciparum malaria treated with ACT that were undertaken in regions coendemic for P. vivax between 1 January 1960 and 5 January 2018. Data from eligible studies were pooled using standardised methodology. The risk of P. vivax parasitaemia at days 42 and 63 and associated risk factors were investigated by multivariable Cox regression analyses. Study quality was assessed using a tool developed by the Joanna Briggs Institute. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018097400). In total, 42 studies enrolling 15,341 patients were included in the analysis, including 30 randomised controlled trials and 12 cohort studies. Overall, 14,146 (92.2%) patients had P. falciparum monoinfection and 1,195 (7.8%) mixed infection with P. falciparum and P. vivax. The median age was 17.0 years (interquartile range [IQR] = 9.0-29.0 years; range = 0-80 years), with 1,584 (10.3%) patients younger than 5 years. 2,711 (17.7%) patients were treated with artemether-lumefantrine (AL, 13 studies), 651 (4.2%) with artesunate-amodiaquine (AA, 6 studies), 7,340 (47.8%) with artesunate-mefloquine (AM, 25 studies), and 4,639 (30.2%) with dihydroartemisinin-piperaquine (DP, 16 studies). 14,537 patients (94.8%) were enrolled from the Asia-Pacific region, 684 (4.5%) from the Americas, and 120 (0.8%) from Africa. At day 42, the cumulative risk of vivax parasitaemia following treatment of P. falciparum was 31.1% (95% CI 28.9-33.4) after AL, 14.1% (95% CI 10.8-18.3) after AA, 7.4% (95% CI 6.7-8.1) after AM, and 4.5% (95% CI 3.9-5.3) after DP. By day 63, the risks had risen to 39.9% (95% CI 36.6-43.3), 42.4% (95% CI 34.7-51.2), 22.8% (95% CI 21.2-24.4), and 12.8% (95% CI 11.4-14.5), respectively. In multivariable analyses, the highest rate of P. vivax parasitaemia over 42 days of follow-up was in patients residing in areas of short relapse periodicity (adjusted hazard ratio [AHR] = 6.2, 95% CI 2.0-19.5; p = 0.002); patients treated with AL (AHR = 6.2, 95% CI 4.6-8.5; p < 0.001), AA (AHR = 2.3, 95% CI 1.4-3.7; p = 0.001), or AM (AHR = 1.4, 95% CI 1.0-1.9; p = 0.028) compared with DP; and patients who did not clear their initial parasitaemia within 2 days (AHR = 1.8, 95% CI 1.4-2.3; p < 0.001). The analysis was limited by heterogeneity between study populations and lack of data from very low transmission settings. Study quality was high. CONCLUSIONS In this meta-analysis, we found a high risk of P. vivax parasitaemia after treatment of P. falciparum malaria that varied significantly between studies. These P. vivax infections are likely attributable to relapses that could be prevented with radical cure including a hypnozoitocidal agent; however, the benefits of such a novel strategy will vary considerably between geographical areas.
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Affiliation(s)
- Mohammad S. Hossain
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- International Centre for Diarrheal Diseases and Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Robert J. Commons
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Internal Medical Services, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Nicholas M. Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Bereket H. Alemayehu
- ICAP at Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | | | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | | | - Verena I. Carrara
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Chanthap Lon
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | | | - Timothy M. E. Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
| | - Arjen M. Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Michael D. Edstein
- Australian Defence Force Malaria and Infectious Disease Institute, Enoggera, Brisbane, Australia
| | - Rick M. Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Marcelo U. Ferreira
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Jimee Hwang
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | | | - Harin Karunajeewa
- Melbourne Medical School–Western Health, The University of Melbourne, Melbourne, Australia
- Western Health Chronic Disease Alliance, Sunshine Hospital, St Albans, Melbourne, Australia
| | - Jean R. Kiechel
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Simone Ladeia-Andrade
- Laboratory of Parasitic Diseases, Oswaldo Cruz Institute/Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
- Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil
| | - Moses Laman
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane, Lao PDR
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Brioni R. Moore
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Australia
| | - Ivo Mueller
- Division of Population Health and Immunity, The Walter & Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Parasites and Insect Vectors Department, Institut Pasteur, Paris, France
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Harald Noedl
- MARIB—Malaria Research Initiative Bandarban, Vienna, Austria
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Aung P. Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Jeanne R. Poespoprodjo
- Mimika District Hospital, Timika, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
- Paediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - David L. Saunders
- Division of Medicine, United States Army Research Institute of Infectious Diseases, Ft. Detrick, Maryland, United States of America
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
| | - Michele D. Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Yupin Suputtamongkol
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Department of Parasitology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Hien T. Tran
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
| | - Neena Valecha
- National Institute of Malaria Research, Dwarka, New Delhi, India
| | | | - Michele Van Vugt
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Academic Medical Centre, Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Nicholas J. White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
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