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Woldesenbet D, Birhanie M, Abere A, Zeleke AJ, Bezabih MK, Semaw M, Wubetie M, Abebe W, Tamene E, Tegegne Y. Therapeutic efficacy and safety of artemether-lumefantrine combination therapy for the treatment of uncomplicated Plasmodium falciparum malaria at Teda Health Centre, Northwest Ethiopia, 2022/23. Malar J 2024; 23:266. [PMID: 39215366 PMCID: PMC11363363 DOI: 10.1186/s12936-024-05082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 08/17/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND The emergence of Plasmodium falciparum drug resistance against artemisinin-based combination therapy has threatened malaria control efforts. Since malaria control and elimination plans are dependent on these drugs, they must remain efficacious. However, resistance to these drugs was detected in low-transmission settings and is predicted to emerge in high-transmission settings, including in unspecified areas of Ethiopia. Therefore, this study aimed to assess the therapeutic efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated P. falciparum malaria. METHODS A single-arm prospective observational study was conducted at Teda Health Centre, Northwest Ethiopia, by following the 2009 World Health Organization efficacy study guidelines from September 2022 to February 2023. Patients with uncomplicated falciparum malaria were conveniently selected and treated with a standard dose of artemether-lumefantrine, along with a single low dose of primaquine. Then clinical and parasitological responses and haemoglobin levels were assessed during the 28-day scheduled follow-up. Blood films were examined and asexual parasites were quantified; axillary temperature was measured; and drug adverse events were assessed throughout the follow-up. Finally, the drug efficacy (adequate clinical and parasitological response) was determined by Kaplan-Meier and per-protocol analyses. The data were analysed using the WHO Excel spreadsheet and SPSS version 25 software. RESULTS The success rates of PCR uncorrected and corrected Kaplan-Meier analysis on day 28 were 95.8% (95% CI 87.5-98.6) and 97.3% (95% CI 89.4-99.3), respectively. The per-protocol PCR uncorrected and corrected adequate clinical and parasitological responses were 95.5% (95% CI 87.5-99.1) and 97% (95% CI 89.5-99.6), respectively. On day-3, 97% of study participants were free of asexual parasitaemia, and all of them were fever-free on day-2. All of the gametocyte-positive patients at baseline were found to be negative for gametocytes on day-2. Moreover, the baseline mean hemoglobin of 13.10 g/dl increased slightly on day-14 to 13.27 g/dl but significantly on day-28 to 13.69 g/dl in a paired sample t test. All adverse events reported were mild. CONCLUSION Artemether-lumefantrine continued to be an efficacious and safe drug for the treatment of uncomplicated Plasmodium falciparum malaria at the Teda Health Centre. TRIAL REGISTRATION unique ID# PACTR202309773069812 at https://pactr.samrc.ac.za on September 1, 2023.
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Affiliation(s)
- Dagmawi Woldesenbet
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia.
| | - Meseret Birhanie
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aberham Abere
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ayalew Jejaw Zeleke
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Migbaru Keffale Bezabih
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Muluken Semaw
- Medical Laboratory Unit, Sanja General Hospital, Amhara National Regional State Health Bureau, Sanja, Ethiopia
| | - Menberu Wubetie
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Wagaw Abebe
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Elias Tamene
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Yalewayker Tegegne
- Department of Medical Parasitology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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2
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Alebachew M, Gelaye W, Abate MA, Sime H, Hailgiorgis H, Gidey B, Haile M, Assefa G, Bekele W, Belay H, Parr JB, Tasew G, Mohammed H, Assefa A. Therapeutic efficacy of pyronaridine-artesunate (Pyramax ®) against uncomplicated Plasmodium falciparum infection at Hamusit Health Centre, Northwest Ethiopia. Malar J 2023; 22:186. [PMID: 37330475 PMCID: PMC10276904 DOI: 10.1186/s12936-023-04618-y] [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: 04/05/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Early case detection and prompt treatment are important malaria control and elimination strategies. However, the emergence and rapid spread of drug-resistant strains present a major challenge. This study reports the first therapeutic efficacy profile of pyronaridine-artesunate against uncomplicated Plasmodium falciparum in Northwest Ethiopia. METHODS This single-arm prospective study with 42-day follow-up period was conducted from March to May 2021 at Hamusit Health Centre using the World Health Organization (WHO) therapeutic efficacy study protocol. A total of 90 adults ages 18 and older with uncomplicated falciparum malaria consented and were enrolled in the study. A standard single-dose regimen of pyronaridine-artesunate was administered daily for 3 days, and clinical and parasitological outcomes were assessed over 42 days of follow-up. Thick and thin blood films were prepared from capillary blood and examined using light microscopy. Haemoglobin was measured and dried blood spots were collected on day 0 and on the day of failure. RESULTS Out of 90 patients, 86/90 (95.6%) completed the 42-day follow-up study period. The overall PCR-corrected cure rate (adequate clinical and parasitological response) was very high at 86/87 (98.9%) (95% CI: 92.2-99.8%) with no serious adverse events. The parasite clearance rate was high with fast resolution of clinical symptoms; 86/90 (95.6%) and 100% of the study participants cleared parasitaemia and fever on day 3, respectively. CONCLUSION Pyronaridine-artesunate was highly efficacious and safe against uncomplicated P. falciparum in this study population.
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Affiliation(s)
- Mihreteab Alebachew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Wollo University, P.O Box 1145, Dessie, Ethiopia
| | - Woyneshet Gelaye
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Megbaru Alemu Abate
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- The Unversity of Queensland, School of Public Health, Brisbane, Australia
| | - Heven Sime
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Henok Hailgiorgis
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Bokretsion Gidey
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Gudissa Assefa
- Ethiopian Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Worku Bekele
- World Health Organization, Addis Ababa, Ethiopia
| | - Habtamu Belay
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Jonathan B. Parr
- Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Geremew Tasew
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Hussein Mohammed
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ashenafi Assefa
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic and Zoonotic Disease Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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Funwei RI, Uyaiabasi GN, Hammed WA, Ojurongbe O, Walker O, Falade CO. High prevalence of persistent residual parasitemia on days 3 and 14 after artemether-lumefantrine or pyronaridine-artesunate treatment of uncomplicated Plasmodium falciparum malaria in Nigeria. Parasitol Res 2023; 122:519-526. [PMID: 36510009 DOI: 10.1007/s00436-022-07753-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Microscopic evaluation of parasite clearance is the gold standard in antimalarial drug efficacy trials. However, the presence of sub-microscopic residual parasitemia after artemisinin-based combination therapy (ACT) needs to be investigated. METHODS One hundred and twenty (AL: n = 60, PA: n = 60) days 3 and 14 dried blood spots, negative by microscopy were analysed for residual parasitemia using nested PCR. Isolates with residual parasitemia on days 3 and 14 were further genotyped with their corresponding day-0 isolates using merozoite surface proteins msp-1, msp-2, and glurp genes for allelic similarity. RESULTS Persistent PCR-determined sub-microscopic residual parasitemia at day 3 post ACT treatment was 83.3 (AL) and 88.3% (PA), respectively (ρ = 0.600), while 63.6 and 36.4% (ρ = 0.066) isolates were parasitemic at day 14 for AL and PA, respectively. Microscopy-confirmed gametocytemia persisted from days 0 to 7 and from days 0 to 21 for AL and PA. When the alleles of day 3 versus day 0 were compared according to base pair sizes, 59% of parasites shared identical alleles for glurp, 36% each for 3D7 and FC27, while K1 was 77%, RO33 64%, and MAD20 23%, respectively. Similarly, day 14 versus day 0 was 36% (glurp), 64% (3D7), and 32% (FC27), while 73% (K1), 77% (RO33), and 41% (MAD20), respectively. CONCLUSION The occurrence of residual parasitemia on days 3 and 14 following AL or PA treatment may be attributable to the presence of either viable asexual, gametocytes, or dead parasite DNAs, which requires further investigation.
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Affiliation(s)
- Roland I Funwei
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria. .,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria.
| | - Gabriel N Uyaiabasi
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria.,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Wasiu A Hammed
- Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Olusola Ojurongbe
- Department of Medical Microbiology, Ladoke Akintola University of Technology, Ogbomosho, Oyo State, Nigeria.,Center for Emerging and Re-Emerging Infectious Diseases (CERID), Ladoke Akintola University of Technology, Ogbomosho, Oyo State, Nigeria
| | - Oladapo Walker
- Department of Pharmacology, Babcock University, Ilishan-Remo, Ogun State, Nigeria.,Center for Advanced Medical Research and Biotechnology (CAMRAB), Babcock University, Ilishan-Remo, Ogun State, Nigeria
| | - Catherine O Falade
- Department of Pharmacology and Therapeutics, University of Ibadan, Ibadan, Nigeria.,Institute for Advanced Medical Research and Training (IAMRAT), University of Ibadan, Ibadan, Nigeria
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Gubae K, Mohammed H, Sime H, Hailgiorgis H, Mare AK, Gidey B, Haile M, Assefa G, Bekele W, Tasew G, Abay SM, Assefa A. Safety and therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria at Shecha health centre, Arba Minch, Ethiopia. Malar J 2023; 22:9. [PMID: 36611179 PMCID: PMC9824982 DOI: 10.1186/s12936-022-04436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In 2004, Ethiopia adopted artemether-lumefantrine (AL, Coartem®) as first-line treatment for the management of uncomplicated Plasmodium falciparum malaria. Continuous monitoring of AL therapeutic efficacy is crucial in Ethiopia, as per the World Health Organization (WHO) recommendation. This study aimed to assess the therapeutic efficacy of AL in the treatment of uncomplicated P. falciparum infection. METHODS A 28 day onearm, prospective evaluation of the clinical and parasitological response to AL was conducted at Shecha Health Centre, Arba Minch town, Southern Ethiopia. Patients were treated with six-dose regimen of AL over three days and monitored for 28 days with clinical and laboratory assessments. Participant recruitment and outcome classification was done in accordance with the 2009 WHO methods for surveillance of anti-malarial drug efficacy guidelines. RESULTS A total of 88 study participants were enrolled and 69 of them completed the study with adequate clinical and parasitological response. Two late parasitological failures were observed, of which one was classified as a recrudescence by polymerase chain reaction (PCR). The PCRcorrected cure rate was 98.6% (95% CI 92.3-100). AL demonstrated a rapid parasite and fever clearance with no parasitaemia on day 2 and febrile cases on day 3. Gametocyte clearance was complete by day three. No serious adverse events were reported during the 28 days follow-up. CONCLUSION The study demonstrated high therapeutic efficacy and good safety profile of AL. This suggests the continuation of AL as the first-line drug for the treatment of uncomplicated P. falciparum malaria in Ethiopia. Periodic therapeutic efficacy studies and monitoring of markers of resistance are recommended for early detection of resistant parasites.
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Affiliation(s)
- Kale Gubae
- grid.449044.90000 0004 0480 6730Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia ,grid.7123.70000 0001 1250 5688Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hussein Mohammed
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Heven Sime
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Henok Hailgiorgis
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Anteneh Kassahun Mare
- grid.7123.70000 0001 1250 5688Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bokretsion Gidey
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Mebrahtom Haile
- grid.414835.f0000 0004 0439 6364Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Gudissa Assefa
- grid.414835.f0000 0004 0439 6364Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Worku Bekele
- World Health Organization, Addis Ababa, Ethiopia
| | - Geremew Tasew
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Solomon Mequanente Abay
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Ashenafi Assefa
- grid.452387.f0000 0001 0508 7211Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia ,grid.10698.360000000122483208Institute of Infectious Disease and Global Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Marwa K, Kapesa A, Baraka V, Konje E, Kidenya B, Mukonzo J, Kamugisha E, Swedberg G. Therapeutic efficacy of artemether-lumefantrine, artesunate-amodiaquine and dihydroartemisinin-piperaquine in the treatment of uncomplicated Plasmodium falciparum malaria in Sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2022; 17:e0264339. [PMID: 35271592 PMCID: PMC8912261 DOI: 10.1371/journal.pone.0264339] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background Sub-Saharan Africa has the highest burden of malaria in the world. Artemisinin-based combination therapies (ACTs) have been the cornerstone in the efforts to reduce the global burden of malaria. In the effort to facilitate early detection of resistance for artemisinin derivatives and partner drugs, WHO recommends monitoring of ACT’s efficacy in the malaria endemic countries. The present systematic meta-analysis study summarises the evidence of therapeutic efficacy of the commonly used artemisinin-based combinations for the treatment of uncomplicated P. falciparum malaria in Sub-Saharan Africa after more than a decade since the introduction of the drugs. Methods Fifty two studies carried out from 2010 to 2020 on the efficacy of artemether-lumefantrine or dihydro-artemisinin piperaquine or artesunate amodiaquine in patients with uncomplicated P. falciparum malaria in Sub-Saharan Africa were searched for using the Google Scholar, Cochrane Central Register of controlled trials (CENTRAL), PubMed, Medline, LILACS, and EMBASE online data bases. Data was extracted by two independent reviewers. Random analysis effect was performed in STATA 13. Heterogeneity was established using I2 statistics. Results Based on per protocol analysis, unadjusted cure rates in malaria infected patients treated with artemether-lumefantrine (ALU), artesunate-amodiaquine (ASAQ) and dihydroartemisinin-piperaquine (DHP) were 89%, 94% and 91% respectively. However, the cure rates after PCR correction were 98% for ALU, 99% for ASAQ and 99% for DHP. Conclusion The present meta-analysis reports the overall high malaria treatment success for artemether-lumefantrine, artesunate-amodiaquine and dihydroartemisinin-piperaquine above the WHO threshold value in Sub-Saharan Africa.
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Affiliation(s)
- Karol Marwa
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- * E-mail: ,
| | - Anthony Kapesa
- Department of Community Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Vito Baraka
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Evelyne Konje
- Department of Epidemiology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Benson Kidenya
- Department of Biochemistry, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Jackson Mukonzo
- Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Erasmus Kamugisha
- Department of Biochemistry, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Gote Swedberg
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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Abamecha A, Yilma D, Adissu W, Yewhalaw D, Abdissa A. Efficacy and safety of artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Ethiopia: a systematic review and meta-analysis. Malar J 2021; 20:213. [PMID: 33957925 PMCID: PMC8101141 DOI: 10.1186/s12936-021-03745-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background Regular monitoring of anti-malarial drug efficacy is vital for establishing rational malaria treatment guidelines and ensuring adequate treatment outcomes. This study aimed to synthesize the available evidence on the efficacy of artemether–lumefantrine for the management of uncomplicated falciparum malaria in Ethiopia. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Relevant published studies were searched from the databases (PubMed, Google Scholar and Clinical trial registry) on published artemether–lumefantrine therapeutic efficacy studies conducted in Ethiopia from 2004 to 2020. The retrieved studies were assessed for quality using the modified Newcastle Ottawa Scale for observational studies and modified Jadad scale for interventional studies. Risk of bias was also assessed by using ROBINS-I tool. OpenMeta-Analyst software was used for the statistical analysis. The review protocol is registered in PROSPERO, number CRD42020201859. Results Fifteen studies (1523 participants) were included in the final analysis. The overall PCR-uncorrected pooled proportion of treatment success of artemether–lumefantrine therapy for uncomplicated falciparum malaria was 98.4% (95%CI 97.6–99.1). A random-effects model was used because of considerable heterogeneity [χ2 = 20.48, df (14), P = 0.011 and I2 = 31.65]. PCR-corrected pooled proportion of treatment success of artemether–lumefantrine therapy was 98.7% (95% CI 97.7–99.6). A random-effects model was used [χ2 = 7.37, df(6), P = 0.287 and I2 = 18.69]. Most studies included in the present review achieved a rapid reduction of fevers and parasitaemia between D0 and D3 of assessment. Adverse events were mostly mild and only two cases were reported as serious, but were not directly attributed to the drug. Conclusion The present meta-analysis suggests that artemether–lumefantrine therapy is efficacious and safe in treating uncomplicated falciparum malaria in Ethiopia. However, owing to the high risk of bias in the included studies, strong conclusions cannot be drawn. Further high-quality RCTs assessing anti-malarial efficacy and safety should be performed to demonstrates strong evidence of changes in parasite sensitivity to artemether–lumefantrine in Ethiopia. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03745-8.
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Affiliation(s)
- Abdulhakim Abamecha
- School of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia. .,Clinical Trial Unit, Jimma University, Jimma, Ethiopia. .,Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia. .,Department of Biomedical, College of Public Health and Medical Science, Mettu University, Mettu, Ethiopia.
| | - Daniel Yilma
- Department of Internal Medicine, Institute of Health, Jimma University, Jimma, Ethiopia.,Clinical Trial Unit, Jimma University, Jimma, Ethiopia
| | - Wondimagegn Adissu
- School of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia.,Clinical Trial Unit, Jimma University, Jimma, Ethiopia
| | - Delenasaw Yewhalaw
- School of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia.,Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia.,Clinical Trial Unit, Jimma University, Jimma, Ethiopia.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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Therapeutic Efficacy of Artemether-Lumefantrine (Coartem®) for the Treatment of Uncomplicated Falciparum Malaria in Africa: A Systematic Review. J Parasitol Res 2020; 2020:7371681. [PMID: 33145101 PMCID: PMC7599419 DOI: 10.1155/2020/7371681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/09/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Africa still bears the largest burden of malaria as the majority of infections in the continent are caused by P. falciparum. Artemether-lumefantrine (AL, Coartem®) is the most widely used artemisinin-based combination therapy (ACT), for treating uncomplicated falciparum malaria globally. However, the development of resistance to antimalarial drugs is a major challenge for malaria control. In this review, the efficacy of AL for the treatment of uncomplicated falciparum malaria in Africa was evaluated. Methods Articles published between January 2015 and July 2019 were systematically searched using comprehensive search strings from PubMed/Medline, SCOPUS, and grey literature from Google Scholar. Interventional studies that followed patients for at least 28 days were included. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. All the included articles were measured to be good quality. While computing the efficacy of AL, polymerase chain reaction (PCR)–corrected cure rate (adequate clinical and parasitological response, ACPR) at day 28 was considered as the main endpoint. Meta-analysis was computed using STATA v 15 to calculate the pooled ACPR. Results In this review, 39 articles that reported the treatment outcome of 8,320 patients were included. After 28 days of follow-up, the pooled PCR uncorrected and corrected APCR was at 87% (95% CI: 85-90%) and 97.0% (95% CI: 96-98%), respectively. Moreover, the proportion of early treatment failure (ETF) was almost 0%, while most of the included articles reported <8% late treatment failures. The reinfection and recrudescence rate was less than 10% and 2.6%, respectively, within 28 days. We noted rapid fever and parasite clearance in which greater than 93% and 94% patients were parasite and fever free at day three following AL treatment. Conclusions This review discovered that despite more than a decade since its introduction, Coartem® remains effective and thus could continue to be the drug of choice for the treatment of uncomplicated falciparum malaria for all age groups in Africa. However, the risk of new emerging resistance for this combination warrants regular monitoring of its efficacy across the continent.
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Abamecha A, Yilma D, Addisu W, El-Abid H, Ibenthal A, Noedl H, Yewhalaw D, Moumni M, Abdissa A. Therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Chewaka District, Ethiopia. Malar J 2020; 19:240. [PMID: 32650784 PMCID: PMC7350688 DOI: 10.1186/s12936-020-03307-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background The efficacy of artemether-lumefantrine (AL) for treatment of uncomplicated Plasmodium falciparum malaria in south-western Ethiopia is poorly documented. Regular monitoring of drug efficacy is an important tool for supporting national treatment policies and practice. This study investigated the therapeutic efficacy of AL for the treatment of P. falciparum malaria in Ethiopia. Methods The study was a one-arm, prospective, evaluation of the clinical and parasitological, responses to directly observed treatment with AL among participants 6 months and older with uncomplicated P. falciparum malaria. Real-time polymerase chain reaction (PCR) and nested PCR reaction methods were used to quantify and genotype P. falciparum. A modified protocol based on the World Health Organization 2009 recommendations for the surveillance of anti-malarial drug efficacy was used for the study with primary outcomes, clinical and parasitological cure rates at day-28. Secondary outcomes assessed included patterns of fever and parasite clearance. Cure rate on day-28 was assessed by intention to treat (ITT) and per protocol (PP) analysis. Parasite genotyping was also performed at baseline and at the time of recurrence of parasitaemia to differentiate between recrudescence and new infection. Results Of the 80 study participants enrolled, 75 completed the follow-up at day-28 with ACPR. For per protocol (PP) analysis, PCR-uncorrected and-corrected cure rate of AL among the study participants was 94.7% (95% CI 87.1–98.5) and 96% (95% CI 88.8–99.2), respectively. For intention to treat (ITT) analysis, the cure rate was 90% (95% CI 88.8–99.2). Based on Kaplan–Meier survival estimate, the cumulative incidence of failure rate of AL was 3.8% (95% CI 1.3–11.4). Only three participants 3.8% (95% CI 0.8–10.6) of the 80 enrolled participants were found to be positive on day-3. The day three-positive participants were followed up to day 28 and did not correspond to treatment failures observed during follow-up. Only 7.5% (6/80) of the participants were gametocyte-positive on enrollment and gametocytaemia was absent on day-2 following treatment with AL. Conclusions The therapeutic efficacy of AL is considerably high (above 90%). AL remained highly efficacious in the treatment of uncomplicated malaria in the study area resulted in rapid fever and parasite clearance as well as low gametocyte carriage rates despite the use of this combination for more than 15 years.
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Affiliation(s)
- Abdulhakim Abamecha
- School of Medical Laboratory Science, Institute of Health, Jimma University, Jimma, Ethiopia. .,Department of Biomedical, College of Public Health and Medical Science, Mettu University, Mettu, Ethiopia. .,Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia.
| | - Daniel Yilma
- Department of Internal Medicine, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Wondimagegn Addisu
- School of Medical Laboratory Science, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Hassan El-Abid
- Biotechnology and Bio-Resources Development Laboratory, Faculty of Sciences, Moulay Ismail University, Meknes, Morocco
| | - Achim Ibenthal
- Faculty of Science and Art, HAWK University, Gottingen, Germany
| | - Harald Noedl
- Malaria Research Initiative Bandarban (MARIB), Vienna, Austria
| | - Delenasaw Yewhalaw
- School of Medical Laboratory Science, Institute of Health, Jimma University, Jimma, Ethiopia.,Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - Mohieddine Moumni
- Biotechnology and Bio-Resources Development Laboratory, Faculty of Sciences, Moulay Ismail University, Meknes, Morocco
| | - Alemseged Abdissa
- School of Medical Laboratory Science, Institute of Health, Jimma University, Jimma, Ethiopia.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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Diallo MA, Yade MS, Ndiaye YD, Diallo I, Diongue K, Sy SA, Sy M, Seck MC, Ndiaye M, Dieye B, Gomis JF, Sow D, Dème AB, Badiane AS, Ndiaye D. Efficacy and safety of artemisinin-based combination therapy and the implications of Pfkelch13 and Pfcoronin molecular markers in treatment failure in Senegal. Sci Rep 2020; 10:8907. [PMID: 32483161 PMCID: PMC7264303 DOI: 10.1038/s41598-020-65553-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/30/2020] [Indexed: 12/02/2022] Open
Abstract
In 2006, Senegal adopted artemisinin-based combination therapy (ACT) as first-line treatment in the management of uncomplicated malaria. This study aimed to update the status of antimalarial efficacy more than ten years after their first introduction. This was a randomized, three-arm, open-label study to evaluate the efficacy and safety of artemether-lumefantrine (AL), artesunate-amodiaquine (ASAQ) and dihydroartemisinin-piperaquine (DP) in Senegal. Malaria suspected patients were screened, enrolled, treated, and followed for 28 days for AL and ASAQ arms or 42 days for DP arm. Clinical and parasitological responses were assessed following antimalarial treatment. Genotyping (msp1, msp2 and 24 SNP-based barcode) were done to differentiate recrudescence from re-infection; in case of PCR-confirmed treatment failure, Pfk13 propeller and Pfcoronin genes were sequenced. Data was entered and analyzed using the WHO Excel-based application. A total of 496 patients were enrolled. In Diourbel, PCR non-corrected/corrected adequate clinical and parasitological responses (ACPR) was 100.0% in both the AL and ASAQ arms. In Kedougou, PCR corrected ACPR values were 98.8%, 100% and 97.6% in AL, ASAQ and DP arms respectively. No Pfk13 or Pfcoronin mutations associated with artemisinin resistance were found. This study showed that AL, ASAQ and DP remain efficacious and well-tolerated in the treatment of uncomplicated P. falciparum malaria in Senegal.
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Affiliation(s)
- Mamadou Alpha Diallo
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal.
| | - Mamadou Samb Yade
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Yaye Die Ndiaye
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Ibrahima Diallo
- National Malaria Control Program (NMCP), Rue Aimé Césaire, Fann Résidence, Dakar, Senegal
| | - Khadim Diongue
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Saidou Abdoul Sy
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Mouhamad Sy
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Mame Cheikh Seck
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Mouhamadou Ndiaye
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Baba Dieye
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Jules François Gomis
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Djiby Sow
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Awa Bineta Dème
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Aida Sadikh Badiane
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
| | - Daouda Ndiaye
- Department of Parasitology and Mycology, Cheikh Anta Diop University, Avenue Cheikh Anta Diop, BP 5005 Fann, Dakar, Senegal
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10
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Ntamabyaliro NY, Burri C, Nzolo DB, Engo AB, Lula YN, Mampunza SM, Nsibu CN, Mesia GK, Kayembe JMN, Likwela JL, Kintaudi LM, Tona GL. Drug use in the management of uncomplicated malaria in public health facilities in the Democratic Republic of the Congo. Malar J 2018; 17:189. [PMID: 29724210 PMCID: PMC5934796 DOI: 10.1186/s12936-018-2332-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 04/25/2018] [Indexed: 02/04/2023] Open
Abstract
Background Malaria the first causes of death from parasitic infection worldwide. Interventions to reduce the burden of malaria have produced a tremendous drop in malaria morbidity and mortality. However, progress is slower in DRC, which shares with Nigeria 39% of deaths related to malaria globally. Inappropriate use of drugs may be one of the factors of this below-average performance. The aim of this study was to describe the use of drugs in the management of uncomplicated malaria in public health facilities in DRC. Methods A drug use study was carried out in DRC from January to March 2014. In each of the former 11 provinces of DRC, one Rural Health Centre, one Urban Health Centre and one General Hospital were selected. In each of them, 100 patient’s files containing prescription of anti-malarials from January to December 2013 were randomly selected. Among them, all of the files with diagnosis of uncomplicated malaria were included in this study. Prescribed anti-malarials, co-prescribed drugs and their indications were collected. Descriptive analyses were performed. Results A total of 2300 files out of 3300 (69.7%) concerned uncomplicated malaria and were included in analysis. Malaria treatment was initiated after a positive RDT or microscopy in 51.5% of cases, upon suspicion without requesting biological confirmation in 37% and despite negative results in 11%. Twenty-nine (29) different treatment regimens were used. The drugs recommended by the National Malaria Control Programme were used in 54.3% of cases (artesunate–amodiaquine 37.4% or artemether–lumefantrine 16.9%). The second most used anti-malarial was quinine (32.4%). Apart from anti-malarials, an average of 3.1 drugs per patient were prescribed, among which antibiotics (67.9%), analgesics and non-steroidal anti-inflammatory (NSAIDs) (all abbreviations to be explicated on first use) (70.6%), vitamins (29.1%), anaemia drugs, including blood transfusion (9.1%) and corticosteroids (5.7%), In 51.4% of cases there was no indication for the concomitant medication. Conclusion Management of uncomplicated malaria in DRC is characterized by a low adherence to treatment policy, numerous treatment regimens, and abundant concomitant medication potentially harmful to the patient. This may contribute to the low performance of DRC in malaria control. Determinant of this irrational use of drugs need to be assessed in order to formulate and implement efficient corrective measures.
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Affiliation(s)
- Nsengi Y Ntamabyaliro
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - Christian Burri
- Division of Medicines Research, Swiss Tropical and Public Health Institute, Basel, Switzerland.,Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Didier B Nzolo
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Aline B Engo
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Yves N Lula
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Epidemiology for Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Samuel M Mampunza
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Centre Neuropsychopathologique, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Célestin N Nsibu
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Département de Pédiatrie, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Gauthier K Mesia
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jean-Marie N Kayembe
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo.,Département de Médecine Interne, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Joris L Likwela
- Programme National de Lutte Contre le Paludisme, Ministère de la Santé, RDC, Kinshasa, Democratic Republic of the Congo
| | | | - Gaston L Tona
- Unité de Pharmacologie Clinique, Faculté de Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
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11
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Prospective Clinical Trial Assessing Species-Specific Efficacy of Artemether-Lumefantrine for the Treatment of Plasmodium malariae, Plasmodium ovale, and Mixed Plasmodium Malaria in Gabon. Antimicrob Agents Chemother 2018; 62:AAC.01758-17. [PMID: 29311086 DOI: 10.1128/aac.01758-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/20/2017] [Indexed: 11/20/2022] Open
Abstract
Treatment recommendations for Plasmodium malariae and Plasmodium ovale malaria are largely based on anecdotal evidence. The aim of this prospective study, conducted in Gabon, was to systematically assess the efficacy and safety of artemether-lumefantrine for the treatment of patients with uncomplicated P. malariae or P. ovale species monoinfections or mixed Plasmodium infections. Patients with microscopically confirmed P. malariae, P. ovale, or mixed-species malaria with at least one of these two Plasmodium species were treated with an oral, fixed-dose combination of artemether-lumefantrine for 3 consecutive days. The primary endpoints were per-protocol PCR-corrected adequate clinical and parasitological response (ACPR) on days 28 and 42. Tolerability and safety were recorded throughout the follow-up period. Seventy-two participants (42 male and 30 female) were enrolled; 62.5% of them had PCR-corrected mixed Plasmodium infections. Per protocol, PCR-corrected ACPR rates were 96.6% (95% confidence interval [CI], 91.9 to 100) on day 28 and 94.2% (95% CI, 87.7 to 100) on day 42. Considering Plasmodium species independently from their coinfecting species, day 42 ACPR rates were 95.5% (95% CI, 89.0 to 100) for P. falciparum, 100% (exact CI, 84.6 to 100) for P. malariae, 100% (exact CI, 76.8 to 100) for P. ovale curtisi, and 90.9% (95% CI, 70.7 to 100) for P. ovale wallikeri Study drug-related adverse events were generally mild or moderate. In conclusion, this clinical trial demonstrated satisfying antimalarial activity of artemether-lumefantrine against P. ovalewallikeri, P. ovale curtisi, P. malariae, and mixed Plasmodium infections, with per-protocol efficacies of 90% to 100% and without evident tolerability or safety concerns. (This trial was registered in the clinical study database ClinicalTrials.gov under the identifier NCT02528279.).
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12
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Ayalew MB. Therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Ethiopia: a systematic review and meta-analysis. Infect Dis Poverty 2017; 6:157. [PMID: 29137664 PMCID: PMC5686809 DOI: 10.1186/s40249-017-0372-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 10/26/2017] [Indexed: 12/11/2022] Open
Abstract
Background As Ethiopia is one of the sub-Saharan countries with a great burden of malaria the effectiveness of first line anti-malarial drugs is the major concern. The aim of this study was to synthesize the available evidence on the efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Ethiopia. This was done by performing a meta-analysis of recent studies conducted in the country on this topic. Methods Studies published between January 2010 and January 2017 that reported on the efficacy of artemether-lumefantrine in the treatment of P. falciparum malaria in Ethiopian patients were searched for using the PubMed and Google Scholar databases. Ten prospective single-arm cohort studies that followed patients for 28–42 days were included in this analysis. All of the included studies were deemed to be of high quality. Results Ten studies involving 1179 patients that were eligible for meta-analysis were identified. At recruitment, the average parasite count per patient was 1 2981/μl of blood. On the third day of treatment, 96.7% and 98.5% of the study subjects become fever-free and parasite-free, respectively. Based on the per protocol analysis, the cure rate after use of artemether-lumefantrine was 98.2% (polymerase chain reaction corrected) and 97.01% (polymerase chain reaction uncorrected) after 28 days of follow-up. The reinfection rate within 28 days was 1.1% and the recrudescence rate was 1.9%. Conclusions This review found that the cure rate for uncomplicated P. falciparum malaria using artemether-lumefantrine in Ethiopia is still high enough to recommend the drug as a first-line agent. There should be careful periodic monitoring of the efficacy of this drug, as treatment failure may occur due to resistance, sub-therapeutic levels that may occur due to non-adherence, or inadequate absorption. Electronic supplementary material The online version of this article (10.1186/s40249-017-0372-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohammed Biset Ayalew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Gondar University, Gondar, Ethiopia.
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13
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Gebreyohannes EA, Bhagavathula AS, Seid MA, Tegegn HG. Anti-malarial treatment outcomes in Ethiopia: a systematic review and meta-analysis. Malar J 2017; 16:269. [PMID: 28673348 PMCID: PMC5496337 DOI: 10.1186/s12936-017-1922-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ethiopia is among countries with a high malaria burden. There are several studies that assessed the efficacy of anti-malarial agents in the country and this systematic review and meta-analysis was performed to obtain stronger evidence on treatment outcomes of malaria from the existing literature in Ethiopia. METHODS A systematic literature search using the preferred reporting items for systematic review and meta-analysis (PRISMA) statement was conducted on studies from Pubmed, Google Scholar, and ScienceDirect databases to identify published and unpublished literature. Comprehensive meta-analysis software was used to perform all meta-analyses. The Cochrane Q and the I 2 were used to evaluate heterogeneity of studies. Random effects model was used to combine studies showing heterogeneity of Cochrane Q p < 0.10 and I 2 > 50. RESULTS Twenty-one studies were included in the final analysis with a total number of 3123 study participants. Treatment outcomes were assessed clinically and parasitologically using World Health Organization guidelines. Adequate clinical and parasitological response was used to assess treatment success at the 28th day. Overall, a significant high treatment success of 92.9% (95% CI 89.1-96.6), p < 0.001, I 2 = 98.39% was noticed. However, treatment success was higher in falciparum malaria patients treated with artemether-lumefantrine than chloroquine for Plasmodium vivax patients [98.1% (97.0-99.2), p < 0.001, I 2 = 72.55 vs 94.7% (92.6-96.2), p < 0.001, I 2 = 53.62%]. Seven studies reported the adverse drug reactions to anti-malarial treatment; of 822 participants, 344 of them were exposed to adverse drug reactions with a pooled event rate of 39.8% (14.1-65.5), p = 0.002. CONCLUSIONS On the basis of this review, anti-malarial treatment success was high (92.9%) and standard regimens showed good efficacy against Plasmodium falciparum (98.1%) and P. vivax (94.7%) infections in Ethiopia, but associated with high rates of adverse drug reactions (ADRs). However, these ADRs were not serious enough to discontinue anti-malarial treatment. The results of this study suggest that the current anti-malarial medications are effective and safe; however, greater priority should be placed on the discovery of new anti-malarial drugs to achieve successful outcomes as resistance seems inevitable since cases of anti-malarial drug resistance have been reported from other areas of the world.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Akshaya Srikanth Bhagavathula
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Mohammed Assen Seid
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Henok Getachew Tegegn
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
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Salvador C, Rafael B, Matsinhe F, Candrinho B, Muthemba R, De Carvalho E, Naueia E, Sacarlal J, Namboze J, Tiago A, Warsame M, Enosse S. Efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria at sentinel sites in Mozambique, 2015. Acta Trop 2017; 171:146-150. [PMID: 28373036 DOI: 10.1016/j.actatropica.2017.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/27/2017] [Indexed: 11/19/2022]
Abstract
The resistance of Plasmodium falciparum to anti-malarial drugs continues to challenge malaria control. We assessed the therapeutic efficacy and safety of artemether-lumefantrine (AL), the first-line treatment of uncomplicated P. falciparum malaria, in children under five years of age in Mozambique. We conducted a prospective one-arm study to evaluate the clinical and parasitological efficacy of AL over 28days at four sentinel sites, using the WHO protocol for assessing the efficacy of antimalarial treatment. msp1, msp2 and glurp genes were analysed by DNA polymerase chain reaction (PCR) to differentiate recrudescence from re-infection with malaria parasites. Haemoglobin concentration was recorded at baseline and on days 7, 14 and 28. A total of 349 children with uncomplicated falciparum malaria were recruited at the four sentinel sites. Adequate clinical and parasitological response to AL on day 28 follow-up varied from 96.3% to 100% after correction by PCR. The drug was well tolerated, and no adverse event related to the drug was reported. AL, the current first-line treatment for uncomplicated falciparum malaria in Mozambique, remains highly efficacious at the study sites. Monitoring of the efficacy of the recommended antimalarial drugs should be continued in order to detect any emerging threat to their efficacy. TRIAL REGISTRATION NUMBER ACTRN12616001680459.
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Affiliation(s)
- Crizolgo Salvador
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Bernardete Rafael
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Francisco Matsinhe
- Programa Nacional de Controlo da Malária, Ministério da Saúde, Maputo, Mozambique
| | - Baltazar Candrinho
- Programa Nacional de Controlo da Malária, Ministério da Saúde, Maputo, Mozambique
| | - Rosália Muthemba
- Programa Nacional de Controlo da Malária, Ministério da Saúde, Maputo, Mozambique
| | - Eva De Carvalho
- World Health Organization, WHO Country Office Maputo, Mozambique
| | - Eva Naueia
- Fundação Ariel Glaser, Maputo, Mozambique
| | - Jahit Sacarlal
- Faculdade de Medicina,Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Armindo Tiago
- Faculdade de Medicina,Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marian Warsame
- World Health Organization, Global Malaria Programme, Geneva, Switzerland.
| | - Sónia Enosse
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
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Ganfon H, Ekanmian G, Amoussou L, Daniel-Garcia E, Allabi AC. Evaluation of the knowledge and attitude of pharmacists about the national malaria control policy in southern Benin. Malar J 2017; 16:231. [PMID: 28569154 PMCID: PMC5452350 DOI: 10.1186/s12936-017-1880-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 05/26/2017] [Indexed: 11/17/2022] Open
Abstract
Background The national strategy against malaria in an endemic country should involve all the health stakeholders. In Benin, the private sector is rarely present in the activities of the National Malaria Control Programme (NMCP), and its surveillance system does not cover private sector outlets that are a non-negligible part of the healthcare system. Objective The aim of this study was to describe the drug delivery practices within private pharmacies of Cotonou and Porto-Novo and the awareness of medicine providers concerning the national policy of malaria treatment. Methods A survey was performed among pharmacy staff members responsible for dispensing medicines and providing advice to patients within pharmacies of Cotonou and Porto-Novo. Dispensing/pharmacy assistants (‘dispensators’) from 82 pharmacies in Cotonou and 19 in Porto-Novo were surveyed. Data entry was performed using Epidata 3.1 software and data analysis was carried out using SPSS software version 21.1. Chi square test was used to compare proportions. A significance threshold of 0.05 was defined for the p value. Results 46% of providers did not know the artemisinin-based combination therapy recommended by the NMCP for treating uncomplicated malaria. 58.7% were not able to recognize the gravity signs of malaria. 89.8% of dispensators were used to deliver an anti-malarial upon patient request, without prior biological confirmation as requested by the NMCP policy. Conclusions Dispensing practices within the studied pharmacies from Cotonou and Porto-Novo were not in adequacy with the NMCP guidelines for uncomplicated malaria, which is a striking weakness in the training of drug providers on key elements of the guidelines for managing malaria. The NMCP needs to help dispensator from private pharmacies sector to standardize drug delivery practices according to its guidelines.
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Affiliation(s)
- Habib Ganfon
- Unité de formation et de recherche en Pharmacie, Faculté des Sciences de la Santé (FSS), Université d'Abomey-Calavi, 01 BP 188, Cotonou, Benin.,Centre d'Information Pharmaco-thérapeutique du Bénin, 06 BP 2610, Cotonou, Benin.,Réseau Médicament et Développement (ReMeD), 35 Rue Daviel, 75013, Paris, France
| | - Giraud Ekanmian
- Centre d'Information Pharmaco-thérapeutique du Bénin, 06 BP 2610, Cotonou, Benin.
| | - Louis Amoussou
- Unité de formation et de recherche en Pharmacie, Faculté des Sciences de la Santé (FSS), Université d'Abomey-Calavi, 01 BP 188, Cotonou, Benin
| | | | - Aurel Constant Allabi
- Unité de formation et de recherche en Pharmacie, Faculté des Sciences de la Santé (FSS), Université d'Abomey-Calavi, 01 BP 188, Cotonou, Benin
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Teklemariam M, Assefa A, Kassa M, Mohammed H, Mamo H. Therapeutic efficacy of artemether-lumefantrine against uncomplicated Plasmodium falciparum malaria in a high-transmission area in northwest Ethiopia. PLoS One 2017; 12:e0176004. [PMID: 28445503 PMCID: PMC5405980 DOI: 10.1371/journal.pone.0176004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/04/2017] [Indexed: 11/18/2022] Open
Abstract
Malaria, particularly due to Plasmodium falciparum, remains a major public health threat in Ethiopia. Artemether-lumefantine (AL) has been the first-line antimalarial drug against uncomplicated P. falciparum malaria in the country since 2004. Regular monitoring of antimalarial drugs is recommended by the World Health Organization (WHO) to help early detection of drug resistant strains of the parasite and contain their rapid spread. The objective of this study was to assess the therapeutic efficacy of AL in a high-transmission setting in Ethiopia. The study site was Setit Humera, northwest Ethiopia. Single-arm prospective study of a 28-day follow-up was conducted from October 2014 to January 2015 according to the revised WHO 2009 drug efficacy study protocol. Study end-points were classified into primary end-point and secondary end-point. While the primary end-point was the day-28 adequate clinical and parasitological response the secondary end-points were clinical and parasitological evaluations (parasite, fever and gametocyte clearance rate, incidence of drug adverse events) and the relative increment in hemoglobin (Hb) level from baseline to day (D) 14 and D28. A total of 92 patients were enrolled and 79 had completed the 28-day follow-up period. The overall cure rate was 98.8% with 95% confidence interval of 0.915-0.998 without polymerase chain reaction correction. The parasite clearance rate was high with fast resolution of clinical symptoms; 100% of the study participants cleared parasitaemia and fever on D3. Gametocyte carriage was reduced from 7% on D0 to 1% on D3 and complete clearance was achieved on D14. Mean Hb concentration significantly increased on D28 compared to that on D14. There was no serious adverse event. AL was efficacious and safe in a high-transmission setting for treatment of uncomplicated falciparum malaria.
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Affiliation(s)
- Michael Teklemariam
- Department of Microbial, Cellular and Molecular Biology; College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ashenafi Assefa
- Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Moges Kassa
- Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Hussien Mohammed
- Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Hassen Mamo
- Department of Microbial, Cellular and Molecular Biology; College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
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17
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Deressa T, Seid ME, Birhan W, Aleka Y, Tebeje BM. In vivo efficacy of artemether-lumefantrine against uncomplicated Plasmodium falciparum malaria in Dembia District, northwest Ethiopia. Ther Clin Risk Manag 2017; 13:201-206. [PMID: 28243110 PMCID: PMC5319406 DOI: 10.2147/tcrm.s127571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Artemether–lumefantrine (AL) has been used as a first-line treatment for uncomplicated Plasmodium falciparum malaria in Ethiopia since 2004. Antimalarial drug resistance is one of the major obstacles for malaria control and curtails the lifespan of several drugs. Thus, continued monitoring of the efficacy of AL is of great public health importance in malaria endemic areas. Objective This study aimed to investigate the therapeutic efficacy and safety of AL for the treatment of uncomplicated P. falciparum malaria in the Dembia district, northwest Ethiopia. Methods A prospective study was conducted from April 2015 to February 2016 at Kola Diba Health Center (KHC) in the Dembia district to determine the therapeutic efficacy and safety of AL for the treatment of uncomplicated P. falciparum monoinfection. Patients were treated with the six-dose regimen of AL over 3 days and followed up for 28 days as per the World Health Organization protocol. Results Of the total 80 patients enrolled in the AL efficacy study, 75 patients completed the 28 days follow-up. None of the participants reported major adverse events. No early treatment failure or late clinical failure were observed during the study, but there were 6 (8.0%) late parasitological failures. The uncorrected per protocol cure rate of AL was 92.0 (95% CI: 85.7–98.3). Treatment with AL cleared parasitemia and fever in >95% of the patients by day 3. Conclusion This study showed that AL is well tolerated and remains efficacious for treatment of uncomplicated P. falciparum malaria in northwest Ethiopia. However, the observed late parasitological failures in this study are of a concern and warrant continued monitoring of drug efficacy as per the World Health Organization recommendations.
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Affiliation(s)
- Tekalign Deressa
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mengistu Endris Seid
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; Australian Institute Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - Wubet Birhan
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yetemwork Aleka
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biniam Mathewos Tebeje
- School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; Molecular Parasitology Laboratory, Queensland Institute of Medical Research, Brisbane, Australia
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18
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Wudneh F, Assefa A, Nega D, Mohammed H, Solomon H, Kebede T, Woyessa A, Assefa Y, Kebede A, Kassa M. Open-label trial on efficacy of artemether/lumefantrine against the uncomplicated Plasmodium falciparum malaria in Metema district, Northwestern Ethiopia. Ther Clin Risk Manag 2016; 12:1293-300. [PMID: 27601913 PMCID: PMC5005000 DOI: 10.2147/tcrm.s113603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Purpose Following the increased Plasmodium falciparum resistance to chloroquine and sulfadoxine/pyrimethamine, Ethiopia adopted artemether/lumefantrine (AL) as the first-line treatment for uncomplicated P. falciparum in 2004. According to the recommendation of the World Health Organization, this study was carried out for regular monitoring of the efficacy of AL in treating the uncomplicated P. falciparum malaria in Metema district, Gondar Zone, Northwest Ethiopia. Patients and methods This is a one-arm prospective 28-day in vivo therapeutic efficacy study among the uncomplicated P. falciparum malaria patients aged 6 months and older. The study was conducted from October 2014 to January 2015, based on the revised World Health Organization protocol of 2009 for surveillance of antimalarial drug therapeutic efficacy study. Standard six-dose regimen of AL was given twice daily for 3 days, and then the treatment outcomes were assessed on days 0, 1, 2, 3, 7, 14, 21, 28, and any other unscheduled day for emergency cases. Results There were 91 study subjects enrolled in this study, of whom 80 study subjects completed the full follow-up schedules and showed adequate clinical and parasitological responses on day 28, with no major adverse event. Per protocol analysis, the unadjusted cure rate of Coartem® was 98.8% (95% confidence interval: 93.3%–100%) in the study area. Recurrence of one P. falciparum case was detected on day 28, with a late parasitological failure rate of 1.2%. No early treatment failure occurred. Complete parasite and fever clearance was observed on day 3. Gametocyte carriage was 4.4% at enrollment that cleared on day 21. Although the difference is statistically not significant, a slight increase in the level of mean hemoglobin from baseline to day 28 was observed. Conclusion The study showed high efficacy and tolerability of Coartem® against uncomplicated P. falciparum malaria, suggesting the continuation as a first-line drug in the study district. However, regular monitoring of the therapeutic efficacy of the drug, possibly with plasma drug-level measurement, is critical among the mobile border population.
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Affiliation(s)
- Feven Wudneh
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa; Biomedical Department, College of Health Sciences and Medicine, Dilla University, Dilla
| | - Ashenafi Assefa
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Desalegn Nega
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Hussien Mohammed
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Hiwot Solomon
- Malaria Research Team, Disease Prevention and Control Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Tadesse Kebede
- Biomedical Department, College of Health Sciences and Medicine, Dilla University, Dilla
| | - Adugna Woyessa
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Yibeltal Assefa
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Amha Kebede
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
| | - Moges Kassa
- Malaria and Other Parasitological and Entomological Research Team, Bacterial, Parasitic and Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute
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19
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Dieye B, Affara M, Sangare L, Joof F, Ndiaye YD, Gomis JF, Ndiaye M, Mbaye A, Diakite M, Sy N, Mbengue B, Deme AB, Daniels R, Ahouidi AD, Dieye T, Abdullahi A, Doumbia S, Ndiaye JL, Diarra A, Ismaela A, Coulibaly M, Welty C, Ngwa AA, Shaffer J, D'Alessandro U, Volkman SK, Wirth DF, Krogstad DJ, Koita O, Nwakanma D, Ndiaye D. West Africa International Centers of Excellence for Malaria Research: Drug Resistance Patterns to Artemether-Lumefantrine in Senegal, Mali, and The Gambia. Am J Trop Med Hyg 2016; 95:1054-1060. [PMID: 27549635 DOI: 10.4269/ajtmh.16-0053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 06/29/2016] [Indexed: 01/09/2023] Open
Abstract
In 2006, artemether-lumefantrine (AL) became the first-line treatment of uncomplicated malaria in Senegal, Mali, and the Gambia. To monitor its efficacy, between August 2011 and November 2014, children with uncomplicated Plasmodium falciparum malaria were treated with AL and followed up for 42 days. A total of 463 subjects were enrolled in three sites (246 in Senegal, 97 in Mali, and 120 in Gambia). No early treatment failure was observed and malaria infection cleared in all patients by day 3. Polymerase chain reaction (PCR)-adjusted adequate clinical and parasitological response (ACPR) was 100% in Mali, and the Gambia, and 98.8% in Senegal. However, without PCR adjustment, ACPR was 89.4% overall; 91.5% in Mali, 98.8% in Senegal, and 64.3% in the Gambia (the lower value in the Gambia attributed to poor compliance of the full antimalarial course). However, pfmdr1 mutations were prevalent in Senegal and a decrease in parasite sensitivity to artesunate and lumefantrine (as measured by ex vivo drug assay) was observed at all sites. Recrudescent parasites did not show Kelch 13 (K13) mutations and AL remains highly efficacious in these west African sites.
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Affiliation(s)
- Baba Dieye
- Cheikh Anta Diop University, Dakar, Senegal
| | | | | | | | | | | | | | | | | | - Ngayo Sy
- Cheikh Anta Diop University, Dakar, Senegal
| | | | - Awa B Deme
- Cheikh Anta Diop University, Dakar, Senegal
| | - Rachel Daniels
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | - Umberto D'Alessandro
- Medical Research Council, The Gambia.,London School of Hygiene and Tropical Medicine, London, United Kingdom.,Institute of Tropical Medicine, Antwerp, Belgium
| | - Sarah K Volkman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,The Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Simmons College School of Nursing and Health Sciences, Boston, Massachusetts
| | - Dyann F Wirth
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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Hassoun N. Modeling Key Malaria Drugs' Impact on Global Health: A Reason to Invest in the Global Health Impact Index. Am J Trop Med Hyg 2016; 94:942-6. [PMID: 26856915 PMCID: PMC4856624 DOI: 10.4269/ajtmh.15-0409] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/10/2015] [Indexed: 11/07/2022] Open
Abstract
Millions of people cannot access good quality essential medicines they need for some of the world's worst diseases like malaria. The World Health Organization estimates that, in 2013, 198 million people became sick with malaria and 584,000 people died of the disease, while the Institute for Health Metrics Evaluation estimates that there were 164,929,872 cases of malaria in 2013 and 854,568 deaths in 2013. There are many attempts to model different aspects of the global burden of tropical diseases like malaria, but it is also important to measure success in averting malaria-related death and disability. This perspective proposes investing in a systematic effort to measure the benefits of health interventions for malaria along the lines of a model embodied in the Global Health Impact Index (global-health-impact.org).
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Affiliation(s)
- Nicole Hassoun
- Department of Philosophy, Binghamton University, Binghamton, New York
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21
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Wang C, Hu S, Chen X, Bai X. Screening and quantification of anticancer compounds in traditional Chinese medicine by hollow fiber cell fishing and hollow fiber liquid/solid-phase microextraction. J Sep Sci 2016; 39:1814-24. [DOI: 10.1002/jssc.201600103] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Caiyun Wang
- School of Pharmacy; Shanxi Medical University; Taiyuan China
| | - Shuang Hu
- School of Pharmacy; Shanxi Medical University; Taiyuan China
| | - Xuan Chen
- School of Pharmacy; Shanxi Medical University; Taiyuan China
| | - Xiaohong Bai
- School of Pharmacy; Shanxi Medical University; Taiyuan China
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