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Achan J, Barry A, Leroy D, Kamara G, Duparc S, Kaszubska W, Gandhi P, Buffet B, Tshilab P, Ogutu B, Taylor T, Krishna S, Richardson N, Ramachandruni H, Rietveld H. Defining the next generation of severe malaria treatment: a target product profile. Malar J 2024; 23:174. [PMID: 38835069 DOI: 10.1186/s12936-024-04986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Severe malaria is a life-threatening infection, particularly affecting children under the age of 5 years in Africa. Current treatment with parenteral artemisinin derivatives is highly efficacious. However, artemisinin partial resistance is widespread in Southeast Asia, resulting in delayed parasite clearance after therapy, and has emerged independently in South America, Oceania, and Africa. Hence, new treatments for severe malaria are needed, and it is prudent to define their characteristics now. This manuscript focuses on the target product profile (TPP) for new treatments for severe malaria. It also highlights preparedness when considering ways of protecting the utility of artemisinin-based therapies. TARGET PRODUCT PROFILE Severe malaria treatments must be highly potent, with rapid onset of antiparasitic activity to clear the infection as quickly as possible to prevent complications. They should also have a low potential for drug resistance selection, given the high parasite burden in patients with severe malaria. Combination therapies are needed to deter resistance selection and dissemination. Partner drugs which are approved for uncomplicated malaria treatment would provide the most rapid development pathway for combinations, though new candidate molecules should be considered. Artemisinin combination approaches to severe malaria would extend the lifespan of current therapy, but ideally, completely novel, non-artemisinin-based combination therapies for severe malaria should be developed. These should be advanced to at least phase 2 clinical trials, enabling rapid progression to patient use should current treatment fail clinically. New drug combinations for severe malaria should be available as injectable formulations for rapid and effective treatment, or as rectal formulations for pre-referral intervention in resource-limited settings. CONCLUSION Defining the TPP is a key step to align responses across the community to proactively address the potential for clinical failure of artesunate in severe malaria. In the shorter term, artemisinin-based combination therapies should be developed using approved or novel drugs. In the longer term, novel combination treatments should be pursued. Thus, this TPP aims to direct efforts to preserve the efficacy of existing treatments while improving care and outcomes for individuals affected by this life-threatening disease.
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Affiliation(s)
| | - Aïssata Barry
- Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Didier Leroy
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | - George Kamara
- Médecins Sans Frontières, Magburaka District Hospital, Freetown, Sierra Leone
| | - Stephan Duparc
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | - Wiweka Kaszubska
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | | | - Bénédicte Buffet
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | | | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Terrie Taylor
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sanjeev Krishna
- Institut Für Tropenmedizin, Eberhard Karls Universität Tübingen, and German Center for Infection Research (Dzif), Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon
- Clinical Academic Group, Institute for Infection and Immunity, St. George's University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Hanu Ramachandruni
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland.
| | - Hans Rietveld
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland.
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Cao VAT, Nguyen TQ, Le Quyen D, Boon WPC, Moors EHM, Dondorp AM, de Haan F, Amaratunga C. Exploring the feasibility of introducing triple artemisinin-based combination therapy in the malaria treatment policy in Vietnam. Malar J 2023; 22:326. [PMID: 37898749 PMCID: PMC10613363 DOI: 10.1186/s12936-023-04763-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND This study investigates the processes regarding changing malaria treatment policies in Vietnam. Moreover, it explores the feasibility of introducing triple artemisinin-based combination therapy (TACT) in Vietnam to support the national malaria control and elimination plan. METHODS Data were collected via 12 in-depth interviews with key stakeholders, combined with a review of policy documents. RESULTS TACT is considered as a useful backup strategy in case future treatment failures with current artemisinin-based combination therapy (ACT) would occur. Moreover, TACT is also considered as a promising strategy to prevent the re-establishment of malaria. However, regulatory procedures and implementation timelines for TACT were expected to be lengthy. Therefore, strategies to engage national decision-makers, regulators, and suppliers should be initiated soon, stipulating the benefits of TACT deployment. In Vietnam, a procedure to apply for an import permit without registration that has previously been applied to the introduction of artesunate-pyronaridine was proposed to accelerate the introduction of TACT. Global-level support through the World Health Organization recommendations and prequalification were considered critical for supporting the introduction of TACT in Vietnam. CONCLUSIONS Appropriate approach strategies and early stakeholder engagement will be needed to accelerate the introduction of TACT in Vietnam.
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Affiliation(s)
- Van Anh Thi Cao
- The University of North Carolina Project Office, Hanoi, Vietnam.
| | - Thieu Quang Nguyen
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | | | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Ellen H M Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Duong MC, Pham OKN, Thai TT, Lee R, Nguyen TP, Nguyen VVC, Nguyen HP. Magnitude and patterns of severe Plasmodium vivax monoinfection in Vietnam: a 4-year single-center retrospective study. Front Med (Lausanne) 2023; 10:1128981. [PMID: 37324161 PMCID: PMC10265633 DOI: 10.3389/fmed.2023.1128981] [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: 12/21/2022] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Infection with Plasmodium vivax is a recognized cause of severe malaria including deaths. The exact burden and patterns of severe P. vivax monoinfections is however still not well quantified, especially in P. vivax endemic regions. We examined the magnitude and patterns of severe malaria caused by monoinfections of P. vivax and associated predictors among patients admitted to a tertiary care center for malaria in Vietnam. Methods A retrospective cohort study was conducted based on the patients' medical records at the Hospital for Tropical Diseases from January 2015 to December 2018. Extracted information included demographic, epidemiologic, clinical, laboratory and treatment characteristics. Results Monoinfections with P. vivax were found in 153 (34.5, 95% CI 30.3-39.1%) patients of whom, uncomplicated and severe malaria were documented in 89.5% (137/153, 95% CI 83.7-93.5%) and 10.5% (16/153, 95% CI 6.5-16.3%), respectively. Patterns of severe malaria included jaundice (8 cases), hypoglycemia (3 cases), shock (2 cases), anemia (2 cases), and cerebral malaria (1 case). Among 153 patients, 73 (47.7%) had classic malaria paroxysm, 57 (37.3%) had >7 days of illness at the time of admission, and 40 (26.1%) were referred from other hospitals. A misdiagnosis as having other diseases from malaria cases coming from other hospitals was up to 32.5% (13/40). Being admitted to hospital after day 7th of illness (AOR = 6.33, 95% CI 1.14-35.30, p = 0.035) was a predictor of severe malaria. Severe malaria was statistically associated with longer hospital length of stay (p = 0.035). Early and late treatment failures and recrudescence were not recorded. All patients recovered completely. Discussion This study confirms the emergence of severe vivax malaria in Vietnam which is associated with delayed hospital admission and increased hospital length of stay. Clinical manifestations of P. vivax infection can be misdiagnosed which results in delayed treatment. To meet the goal of malaria elimination by 2030, it is crucial that the non-tertiary hospitals have the capacity to quickly and correctly diagnose malaria and then provide treatment for malaria including P. vivax infections. More robust studies need to be conducted to fully elucidate the magnitude of severe P. vivax in Vietnam.
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Affiliation(s)
- Minh Cuong Duong
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Thanh Truc Thai
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Rogan Lee
- Centre for Infectious Diseases and Microbiology, Pathology West-ICPMR and Marie Bashir Institute, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | | | - Van Vinh Chau Nguyen
- Department of Health, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Hoan Phu Nguyen
- Medical School, Vietnam National University of Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
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Dhorda M, Amaratunga C, Dondorp AM. Artemisinin and multidrug-resistant Plasmodium falciparum - a threat for malaria control and elimination. Curr Opin Infect Dis 2021; 34:432-439. [PMID: 34267045 PMCID: PMC8452334 DOI: 10.1097/qco.0000000000000766] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Artemisinin-based combination therapies (ACTs) are globally the first-line treatment for uncomplicated falciparum malaria and new compounds will not be available within the next few years. Artemisinin-resistant Plasmodium falciparum emerged over a decade ago in the Greater Mekong Subregion (GMS) and, compounded by ACT partner drug resistance, has caused significant ACT treatment failure. This review provides an update on the epidemiology, and mechanisms of artemisinin resistance and approaches to counter multidrug-resistant falciparum malaria. RECENT FINDINGS An aggressive malaria elimination programme in the GMS has helped prevent the spread of drug resistance to neighbouring countries. However, parasites carrying artemisinin resistance-associated mutations in the P. falciparum Kelch13 gene (pfk13) have now emerged independently in multiple locations elsewhere in Asia, Africa and South America. Notably, artemisinin-resistant infections with parasites carrying the pfk13 R561H mutation have emerged and spread in Rwanda. SUMMARY Enhancing the geographic coverage of surveillance for resistance will be key to ensure prompt detection of emerging resistance in order to implement effective countermeasures without delay. Treatment strategies designed to prevent the emergence and spread of multidrug resistance must be considered, including deployment of triple drug combination therapies and multiple first-line therapies.
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Affiliation(s)
- Mehul Dhorda
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chanaki Amaratunga
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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