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Yobi DM, Kayiba NK, Mvumbi DM, Boreux R, Kabututu PZ, Akilimali PZ, Situakibanza HNT, De Mol P, Speybroeck N, Mvumbi GL, Hayette MP. Biennial surveillance of Plasmodium falciparum anti-malarial drug resistance markers in Democratic Republic of Congo, 2017 and 2019. BMC Infect Dis 2022; 22:145. [PMID: 35144535 PMCID: PMC8830975 DOI: 10.1186/s12879-022-07112-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Because of the loss of chloroquine (CQ) effectiveness, the Democratic Republic of Congo (DRC)’s malaria treatment policy replaced CQ by sulfadoxine–pyrimethamine (SP) as first-line treatment of uncomplicated malaria in 2003, which in turn was replaced by artemisinin-based combination therapies (ACT) in 2005. The World Health Organization (WHO) recommends monitoring of anti-malarial drug resistance every 2 years. The study aimed to provide baseline data for biennial molecular surveillance of anti-malarial drug resistance by comparing data from a study conducted in 2019 to previously published data from a similar study conducted in 2017 in the DRC. Methods From July to November 2019, a cross-sectional study was conducted in ten sites which were previously selected for a similar study conducted in 2017 across the DRC. P. falciparum malaria was diagnosed by a rapid diagnostic test (RDT) or by microscopy and dried blood samples (DBS) were taken from patients who had a positive test. Segments of interest in pfcrt and pfk13 genes were amplified by conventional PCR before sequencing. Results Out of 1087 enrolled patients, 906 (83.3%) were PCR-confirmed for P. falciparum. Like in the 2017-study, none of the mutations known to be associated with Artemisinine (ART) resistance in Southeast Asia was detected. However, non-synonymous (NS) mutations with unknown functions were observed among which, A578S was detected in both 2017 and 2019-studies. The overall prevalence of pfcrt-K76T mutation that confers CQ-resistance was 22.7% in 2019-study compared to 28.5% in 2017-study (p-value = 0.069), but there was high variability between sites in the two studies. Like in 2017-study, the pfcrt 72–76 SVMNT haplotype associated with resistance to amodiaquine was not detected. Conclusion The study reported, within 2 years, the non-presence of molecular markers currently known to be associated with resistance to ART and to AQ in P. falciparum isolated in the DRC. However, the presence of polymorphisms with as-yet unknown functions was observed, requiring further characterization. Moreover, an overall decrease in the prevalence of CQ-resistance marker was observed in the DRC, but this prevalence remained highly variable from region to region. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07112-z.
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Affiliation(s)
- Doudou M Yobi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
| | - Nadine K Kayiba
- School of Public Health & Research Institute of Health and Society, Catholic University of Louvain, 1200, Brussels, Belgium.,School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Department of Public Health, Faculty of Medicine, University of Mbujimayi, Mbuji-Mayi, Democratic Republic of Congo
| | - Dieudonné M Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Raphael Boreux
- Laboratory of Clinical Microbiology, University of Liège, 4000, Liège, Belgium
| | - Pius Z Kabututu
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pierre Z Akilimali
- School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Hippolyte N T Situakibanza
- Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Patrick De Mol
- Laboratory of Clinical Microbiology, University of Liège, 4000, Liège, Belgium
| | - Niko Speybroeck
- School of Public Health & Research Institute of Health and Society, Catholic University of Louvain, 1200, Brussels, Belgium
| | - Georges L Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
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2
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Identification of polymorphisms in genes associated with drug resistance in Plasmodium falciparum isolates from school-age children in Kinshasa, Democratic Republic of Congo. Parasitol Int 2022; 88:102541. [PMID: 35051550 DOI: 10.1016/j.parint.2022.102541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The emergence and spread of Plasmodium falciparum parasites resistant to antimalarial drugs constitutes an obstacle to malaria control and elimination. This study aimed to identify the prevalence of polymorphisms in pfk13, pfmdr1, pfdhfr, pfdhps and pfcrt genes in isolates from asymptomatic and symptomatic school-age children in Kinshasa. METHODS Nested-PCR followed by sequencing was performed for the detection of pfk13, pfmdr1, pfdhfr, pfdhps and pfcrt polymorphisms. RESULTS Two mutations in pfk13, C532S and Q613E were identified in the Democratic Republic of Congo for the first time. The prevalence of the drug-resistance associated mutations pfcrt K76T, pfdhps K540E and pfmdr1 N86Y was low, being 27%, 20% and 9%, respectively. CONCLUSION We found a low prevalence of genetic markers associated with chloroquine and sulfadoxine-pyrimethamine resistance in Kinshasa. Furthermore, no mutations previously associated with resistance against artemisinin and is derivatives were observed in the pfK13 gene. These findings support the continued use of ACTs and IPTp-SP. Continuous molecular monitoring of antimalarial resistance markers is recommended.
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3
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Deutsch-Feldman M, Brazeau NF, Parr JB, Thwai KL, Muwonga J, Kashamuka M, Tshefu Kitoto A, Aydemir O, Bailey JA, Edwards JK, Verity R, Emch M, Gower EW, Juliano JJ, Meshnick SR. Spatial and epidemiological drivers of Plasmodium falciparum malaria among adults in the Democratic Republic of the Congo. BMJ Glob Health 2021; 5:bmjgh-2020-002316. [PMID: 32601091 PMCID: PMC7326263 DOI: 10.1136/bmjgh-2020-002316] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/17/2022] Open
Abstract
Background Adults are frequently infected with malaria and may serve as a reservoir for further transmission, yet we know relatively little about risk factors for adult infections. In this study, we assessed malaria risk factors among adults using samples from the nationally representative, cross-sectional 2013–2014 Demographic and Health Survey (DHS) conducted in the Democratic Republic of the Congo (DRC). We further explored differences in risk factors by urbanicity. Methods Plasmodium falciparum infection was determined by PCR. Covariates were drawn from the DHS to model individual, community and environmental-level risk factors for infection. Additionally, we used deep sequencing data to estimate the community-level proportions of drug-resistant infections and included these estimates as potential risk factors. All identified factors were assessed for differences in associations by urbanicity. Results A total of 16 126 adults were included. Overall prevalence of malaria was 30.3% (SE=1.1) by PCR; province-level prevalence ranged from 6.7% to 58.3%. Only 17% of individuals lived in households with at least one bed-net for every two people, as recommended by the WHO. Protective factors included increasing within-household bed-net coverage (Prevalence Ratio=0.85, 95% CI=0.76–0.95) and modern housing (PR=0.58, 95% CI=0.49–0.69). Community-level protective factors included increased median wealth (PR=0.87, 95% CI=0.83–0.92). Education, wealth, and modern housing showed protective associations in cities but not in rural areas. Conclusions The DRC continues to suffer from a high burden of malaria; interventions that target high-risk groups and sustained investment in malaria control are sorely needed. Areas of high prevalence should be prioritised for interventions to target the largest reservoirs for further transmission.
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Affiliation(s)
- Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan B Parr
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kyaw L Thwai
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeremie Muwonga
- National AIDS Control Program, Kinshasa, Congo (the Democratic Republic)
| | - Melchior Kashamuka
- School of Public Health, University of Kinshasa Faculty of Medicine, Kinshasa, Congo (the Democratic Republic)
| | - Antoinette Tshefu Kitoto
- School of Public Health, University of Kinshasa Faculty of Medicine, Kinshasa, Congo (the Democratic Republic)
| | - Ozkan Aydemir
- Department of Pathology and Laboratory Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert Verity
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Michael Emch
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emily W Gower
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Curriculum in Genetics and Molecular Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Yobi DM, Kayiba NK, Mvumbi DM, Boreux R, Kabututu PZ, Situakibanza HNT, Umesumbu SE, De Mol P, Speybroeck N, Mvumbi GL, Hayette MP. Assessment of Plasmodium falciparum anti-malarial drug resistance markers in pfk13-propeller, pfcrt and pfmdr1 genes in isolates from treatment failure patients in Democratic Republic of Congo, 2018-2019. Malar J 2021; 20:144. [PMID: 33706773 PMCID: PMC7953712 DOI: 10.1186/s12936-021-03636-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/09/2021] [Indexed: 11/14/2022] Open
Abstract
Background The national policy for malaria treatment of the Democratic Republic of Congo recommends two first-line artemisinin-based combinations for the treatment of uncomplicated malaria: artesunate-amodiaquine and artemether-lumefantrine. This study investigated the presence of markers associated with resistance to the current first-line artemisinin-based combination therapy (ACT) in isolates of Plasmodium falciparum from treatment failure patients in the Democratic Republic of Congo. Methods From November 2018 to November 2019, dried blood spots were taken from patients returning to health centres for fever within 28 days after an initial malaria treatment in six sentinel sites of the National Malaria Control Programme across Democratic Republic of Congo. The new episode of malaria was first detected by a rapid diagnostic test and then confirmed by a real-time PCR assay to define treatment failure. Fragments of interest in pfk13 and pfcrt genes were amplified by conventional PCR before sequencing and the Pfmdr1 gene copy number was determined by a TaqMan real-time PCR assay. Results Out of 474 enrolled patients, 364 (76.8%) were confirmed positive by PCR for a new episode of P. falciparum malaria, thus considered as treatment failure. Of the 325 P. falciparum isolates obtained from 364 P. falciparum-positive patients and successfully sequenced in the pfk13-propeller gene, 7 (2.2%) isolates carried non-synonymous mutations, among which 3 have been previously reported (N498I, N554K and A557S) and 4 had not yet been reported (F506L, E507V, D516E and G538S). Of the 335 isolates successfully sequenced in the pfcrt gene, 139 (41.5%) harboured the K76T mutation known to be associated with chloroquine resistance. The SVMNT haplotype associated with resistance to amodiaquine was not found. None of the isolates carried an increased copy number of the pfmdr1 gene among the 322 P. falciparum isolates successfully analysed. Conclusion No molecular markers currently known to be associated with resistance to the first-line ACT in use were detected in isolates of P. falciparum from treatment failure patients. Regular monitoring through in vivo drug efficacy and molecular studies must continue to ensure the effectiveness of malaria treatment in Democratic Republic of Congo.
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Affiliation(s)
- Doudou M Yobi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
| | - Nadine K Kayiba
- School of Public Health and Research Institute of Health and Society, Catholic University of Louvain, 1200, Brussels, Belgium.,School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Department of Public Health, Faculty of Medicine, University of Mbujimayi, Mbujimayi, Democratic Republic of Congo
| | - Dieudonné M Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Raphael Boreux
- Laboratory of Clinical Microbiology, University of Liège, 4000, Liège, Belgium
| | - Pius Z Kabututu
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Hippolyte N T Situakibanza
- Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Solange E Umesumbu
- National Malaria Control Programme, Kinshasa, Democratic Republic of Congo
| | - Patrick De Mol
- Laboratory of Clinical Microbiology, University of Liège, 4000, Liège, Belgium
| | - Niko Speybroeck
- School of Public Health and Research Institute of Health and Society, Catholic University of Louvain, 1200, Brussels, Belgium
| | - Georges L Mvumbi
- Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
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5
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The impact of antimalarial resistance on the genetic structure of Plasmodium falciparum in the DRC. Nat Commun 2020; 11:2107. [PMID: 32355199 PMCID: PMC7192906 DOI: 10.1038/s41467-020-15779-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 03/28/2020] [Indexed: 11/09/2022] Open
Abstract
The Democratic Republic of the Congo (DRC) harbors 11% of global malaria cases, yet little is known about the spatial and genetic structure of the parasite population in that country. We sequence 2537 Plasmodium falciparum infections, including a nationally representative population sample from DRC and samples from surrounding countries, using molecular inversion probes - a high-throughput genotyping tool. We identify an east-west divide in haplotypes known to confer resistance to chloroquine and sulfadoxine-pyrimethamine. Furthermore, we identify highly related parasites over large geographic distances, indicative of gene flow and migration. Our results are consistent with a background of isolation by distance combined with the effects of selection for antimalarial drug resistance. This study provides a high-resolution view of parasite genetic structure across a large country in Africa and provides a baseline to study how implementation programs may impact parasite populations. The genome of the malaria parasite Plasmodium falciparum contains a record of past evolutionary forces. Here, using 2537 parasite sequences from the Democratic Republic of the Congo, the authors demonstrate how drug pressure and human movement have shaped the present-day parasite population.
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6
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Molecular surveillance of anti-malarial drug resistance in Democratic Republic of Congo: high variability of chloroquinoresistance and lack of amodiaquinoresistance. Malar J 2020; 19:121. [PMID: 32197607 PMCID: PMC7085146 DOI: 10.1186/s12936-020-03192-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background The loss of chloroquine (CQ) effectiveness has led to its withdrawal from national policies as a first-line treatment for uncomplicated malaria in several endemic countries, such as the Democratic Republic of Congo (DRC). The K76T mutation on the pfcrt gene has been identified as a marker of CQ resistance and the SVMNT haplotype in codons 72–76 on the same gene has been associated with resistance to amodiaquine (AQ). In the DRC, the prevalence of K76T has decreased from 100% in 2000 to 63.9% in 2014. The purpose of this study was to determine the prevalence of K76T mutations in circulating strains of Plasmodium falciparum, 16 years after CQ withdrawal in the DRC and to investigate the presence of the SVMNT haplotype. Methods In 2017, ten geographical sites across the DRC were selected. Dried blood samples were collected from patients attending health centres. Malaria was first detected by a rapid diagnostic test (RDT) available on site (SD Bioline Malaria Ag Pf or CareStart Malaria Pf) or thick blood smear and then confirmed by a P. falciparum species-specific real-time PCR assay. A pfcrt gene segment containing a fragment that encodes amino acids at positions 72–76 was amplified by conventional PCR before sequencing. Results A total of 1070 patients were enrolled. Of the 806 PCR-confirmed P. falciparum positive samples, 764 were successfully sequenced. The K76T mutation was detected in 218 samples (28.5%; 95% CI 25.4%–31.9%), mainly (96%) with the CVIET haplotype. Prevalence of CQ resistance marker was unequally distributed across the country, ranging from 1.5% in Fungurume to 89.5% in Katana. The SVMNT haplotype, related to AQ resistance, was not detected. Conclusion Overall, the frequency of the P. falciparum CQ resistance marker has decreased significantly and no resistance marker to AQ was detected in the DRC in 2017. However, the between regions variability of CQ resistance remains high in the country. Further studies are needed for continuous monitoring of the CQ resistance level for its prospective re-use in malaria management. The absence of the AQ resistance marker is in line with the use of this drug in the current DRC malaria treatment policy.
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7
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Deutsch-Feldman M, Aydemir O, Carrel M, Brazeau NF, Bhatt S, Bailey JA, Kashamuka M, Tshefu AK, Taylor SM, Juliano JJ, Meshnick SR, Verity R. The changing landscape of Plasmodium falciparum drug resistance in the Democratic Republic of Congo. BMC Infect Dis 2019; 19:872. [PMID: 31640574 PMCID: PMC6805465 DOI: 10.1186/s12879-019-4523-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Drug resistant malaria is a growing concern in the Democratic Republic of the Congo (DRC), where previous studies indicate that parasites resistant to sulfadoxine/pyrimethamine or chloroquine are spatially clustered. This study explores longitudinal changes in spatial patterns to understand how resistant malaria may be spreading within the DRC, using samples from nation-wide population-representative surveys. METHODS We selected 552 children with PCR-detectable Plasmodium falciparum infection and identified known variants in the pfdhps and pfcrt genes associated with resistance. We compared the proportion of mutant parasites in 2013 to those previously reported from adults in 2007, and identified risk factors for carrying a resistant allele using multivariate mixed-effects modeling. Finally, we fit a spatial-temporal model to the observed data, providing smooth allele frequency estimates over space and time. RESULTS The proportion of co-occurring pfdhps K540E/A581G mutations increased by 16% between 2007 and 2013. The spatial-temporal model suggests that the spatial range of the pfdhps double mutants expanded over time, while the prevalence and range of pfcrt mutations remained steady. CONCLUSIONS This study uses population-representative samples to describe the changing landscape of SP resistance within the DRC, and the persistence of chloroquine resistance. Vigilant molecular surveillance is critical for controlling the spread of resistance.
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Affiliation(s)
- Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.
| | - Ozkan Aydemir
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| | - Margaret Carrel
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, IA, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Samir Bhatt
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| | - Melchior Kashamuka
- Ecole de Santé Publique, , Faculté de Médecine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Ecole de Santé Publique, , Faculté de Médecine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.,Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Curriculum in Genetics and Molecular Biology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Robert Verity
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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8
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Baraka V, Mavoko HM, Nabasumba C, Francis F, Lutumba P, Alifrangis M, Van geertruyden JP. Impact of treatment and re-treatment with artemether-lumefantrine and artesunate-amodiaquine on selection of Plasmodium falciparum multidrug resistance gene-1 polymorphisms in the Democratic Republic of Congo and Uganda. PLoS One 2018; 13:e0191922. [PMID: 29390014 PMCID: PMC5794077 DOI: 10.1371/journal.pone.0191922] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/10/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The emergence of resistance against artemisinin combination treatment is a major concern for malaria control. ACTs are recommended as the rescue treatment, however, there is limited evidence as to whether treatment and re-treatment with ACTs select for drug-resistant P. falciparum parasites. Thus, the purpose of the present study is to investigate the impact of (re-)treatment using artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) on the selection of P. falciparum multidrug resistance-1 (Pfmdr1) alleles in clinical settings. METHODS P. falciparum positive samples were collected from children aged 12-59 months in a clinical trial in DR Congo and Uganda. Pfmdr1 single nucleotide polymorphisms (SNPs) analysis at codons N86Y, Y184F, and D1246Y were performed at baseline and post-treatment with either AL or ASAQ as a rescue treatment using nested PCR followed by restriction fragment length polymorphism (RFLP) assays. RESULTS The pre-treatment prevalence of Pfmdr1 N86 and D1246Y varied significantly between the sites, (p>0.001) and (p = 0.013), respectively. There was borderline significant directional selection for Pfmdr1 184F in recurrent malaria infections after treatment with AL in Uganda site (p = 0.05). Pfmdr1 NFD haplotype did not significantly change in post-treatment infections after re-treatment with either AL or ASAQ. Comparison between pre-treatment and post-treatment recurrences did not indicate directional selection of Pfmdr1 N86, D1246 alleles in the pre-RCT, RCT and post-RCT phases in both AL and ASAQ treatment arms. Pfmdr1 86Y was significantly associated with reduced risk of AL treatment failure (RR = 0.34, 95% CI:0.11-1.05, p = 0.04) while no evidence for D1246 allele (RR = 1.02; 95% CI: 0.42-2.47, p = 1.0). Survival estimates showed that the Pfmdr1 alleles had comparable mean-time to PCR-corrected recrudescence and new infections in both AL and ASAQ treatment arms. CONCLUSION We found limited impact of (re-)treatment with AL or ASAQ on selection for Pfmdr1 variants and haplotypes associated with resistance to partner drugs. These findings further supplement the evidence use of same or alternative ACTs as a rescue therapy for recurrent P.falciparum infections. Continued monitoring of genetic signatures of resistance is warranted to timely inform malaria (re-)treatment policies and guidelines.
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Affiliation(s)
- Vito Baraka
- National Institute for Medical Research, Tanga Centre, Tanga, United Republic of Tanzania
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Hypolite Muhindo Mavoko
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- Département de Médecine Tropicale, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Carolyn Nabasumba
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- Epicentre Mbarara Research Base, Mbarara, Uganda
| | - Filbert Francis
- National Institute for Medical Research, Tanga Centre, Tanga, United Republic of Tanzania
| | - Pascal Lutumba
- Département de Médecine Tropicale, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Michael Alifrangis
- Centre for Medical Parasitology at the Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, National University Hospital (Rigshospitalet), Copenhagen, Denmark
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9
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Muhindo Mavoko H, Kalabuanga M, Delgado-Ratto C, Maketa V, Mukele R, Fungula B, Inocêncio da Luz R, Rosanas-Urgell A, Lutumba P, Van geertruyden JP. Uncomplicated Clinical Malaria Features, the Efficacy of Artesunate-Amodiaquine and Their Relation with Multiplicity of Infection in the Democratic Republic of Congo. PLoS One 2016; 11:e0157074. [PMID: 27280792 PMCID: PMC4900589 DOI: 10.1371/journal.pone.0157074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 05/24/2016] [Indexed: 02/03/2023] Open
Abstract
Background In the Democratic Republic of Congo, artesunate-amodiaquine (ASAQ) is the first-line medication recommended for uncomplicated malaria treatment. We conducted a study in Kinshasa to describe the clinical features of the disease and assess the efficacy of ASAQ and its impact on the multiplicity of infection in children with uncomplicated malaria. Methods Children aged 12 to 59 months with uncomplicated P. falciparum malaria were treated with ASAQ and followed up passively for 42 days. To distinguish new infections from recrudescent parasites, samples were genotyped using a stepwise strategy with three molecular markers (GLURP, MSP2 and MSP1). We then assessed PCR-corrected and -uncorrected day-42 cure rates and multiplicity of infection (MOI). Results In total, 2,796 patients were screened and 865 enrolled in the study. Clinical features were characterized by history of fever (100%), coryza (59.9%) and weakness (59.4%). The crude and PCR-corrected efficacies of ASAQ were 55.3% (95%CI: 51.8–58.8) and 92.8% (95%CI: 91.0–94.6) respectively, as 83.6% (95%CI: 79.1–87.2) of the recurrences were new infections. Compared to monoclonal infections, polyclonal infections were more frequent at enrollment (88.1%) and in recurrences (80.1%; p = 0.005; OR: 1.8, 95%CI: 1.20–2.8). The median MOI at enrollment (MOI = 3.7; IQR: 0.7–6.7) decreased to 3 (IQR: 1–5) in the recurrent samples (p<0.001). Patients infected with a single haplotype on day 0 had no recrudescence; the risk of recrudescence increased by 28% with each additional haplotype (HR: 1.3, 95%CI: 1.24–1.44). Conclusion The PCR-corrected efficacy of ASAQ at day 42 was 92.8%, but crude efficacy was relatively poor due to high reinfection rates. Treatment outcomes were positively correlated with MOI. Continued monitoring of the efficacy of ACTs—ASAQ, in this case—is paramount. Trial Registration ClinicalTrials.gov NCT01374581
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Affiliation(s)
- Hypolite Muhindo Mavoko
- Tropical Medicine Department, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Marion Kalabuanga
- Outpatients Department, Lisungi Health Center, Kinshasa, Democratic Republic of Congo
| | | | - Vivi Maketa
- Tropical Medicine Department, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Rodin Mukele
- Tropical Medicine Department, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Blaise Fungula
- Outpatients Department, Lisungi Health Center, Kinshasa, Democratic Republic of Congo
| | | | | | - Pascal Lutumba
- Tropical Medicine Department, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
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Gabrielli S, Bellina L, Milardi GL, Katende BK, Totino V, Fullin V, Cancrini G. Malaria in children of Tshimbulu (Western Kasai, Democratic Republic of the Congo): epidemiological data and accuracy of diagnostic assays applied in a limited resource setting. Malar J 2016; 15:81. [PMID: 26864461 PMCID: PMC4750168 DOI: 10.1186/s12936-016-1142-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/03/2016] [Indexed: 01/08/2023] Open
Abstract
Background The literature data on malaria in Western Kasai, DRC, are limited and inadequate. A recent molecular survey there has detected Plasmodium ovale and Plasmodium malariae as mixed infections with Plasmodium falciparum. In Tshimbulu, Western Kasai, during a humanitarian initiative designed to provide children with free preventive screening and to reduce the local high malaria death rate, accurate species identification was performed,
in order to collect unambiguous epidemiological data and to evaluate the reliability of locally applied diagnostics. Methods Finger pricks provided fresh blood for microscopic analysis (MA), for rapid diagnostic test (RDT) and for molecular diagnostics (MD). MA and RDT were first performed by the local team and then a re-interpretation of the results (on the same slides and on RDT’s taken pictures) was conducted in Italy, where MD were performed. Results The analysis was conducted on 306 children; RDT found 80.9 % as P. falciparum-positive (37.4 % as two-band positive, P. falciparum single infection). MA identified a further four children as positive to P. falciparum and six co-infections with P. ovale. The second RDT evaluation confirmed a similar infection rate (78.2 %) but interpreted as two-band positive a significantly higher share of tests (56.8 %). MA confirmed 80.0 % of the children as malaria positive and, in addition to P. falciparum, identified P. malariae (13.8 %), P. vivax (3.4 %) and P. ovale (2.4 %), and detected Babesia microti in 19 smears. MD confirmed all of the species found (Babesia microti included), classified as mono-infection with P. falciparum a rate of spots comparable to MA revision, and identified all P. ovale as Plasmodium ovale wallikeri. The RDT used locally proved 93.1 % sensitive and 92.1 % specific for P. falciparum. Conclusions The malaria prevalence among the children and the presence of four Plasmodium species, highlighted in this study, identified a sanitary issue which proved to be more alarming than expected, as it was worsened by the unpredictable presence of P. vivax and Babesia microti (never before reported in DRC). Each diagnostic tool showed its point of weakness. Therefore, the most correct approach is by the combined use of different, locally available, diagnostic tools.
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Affiliation(s)
- Simona Gabrielli
- Dip. Sanità Pubblica e Malattie infettive, Università "Sapienza", P.le Aldo Moro 5, 00185, Rome, Italy.
| | - Livia Bellina
- MobileDiagnosis Onlus, via Sciuti 180, 90144, Palermo, Italy.
| | - Giovanni Luigi Milardi
- Dip. Sanità Pubblica e Malattie infettive, Università "Sapienza", P.le Aldo Moro 5, 00185, Rome, Italy.
| | | | - Valentina Totino
- Dip. Sanità Pubblica e Malattie infettive, Università "Sapienza", P.le Aldo Moro 5, 00185, Rome, Italy.
| | - Valerio Fullin
- St François Hospital, Tshimbulu, BP 185, Kananga, Western Kasai, Democratic Republic of Congo.
| | - Gabriella Cancrini
- Dip. Sanità Pubblica e Malattie infettive, Università "Sapienza", P.le Aldo Moro 5, 00185, Rome, Italy.
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Mvumbi DM, Kayembe JM, Situakibanza H, Bobanga TL, Nsibu CN, Mvumbi GL, Melin P, De Mol P, Hayette MP. Falciparum malaria molecular drug resistance in the Democratic Republic of Congo: a systematic review. Malar J 2015; 14:354. [PMID: 26376639 PMCID: PMC4574228 DOI: 10.1186/s12936-015-0892-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 09/04/2015] [Indexed: 01/22/2023] Open
Abstract
Background Malaria cases were estimated to 207 million in 2013. One of the problems of malaria control is the emergence and spread of Plasmodium falciparum strains that become resistant to almost all drugs available. Monitoring drug resistance is essential for early detection and subsequent prevention of the spread of drug resistance by timely changes of treatment policy. This review was performed to gather all data available on P. falciparum molecular resistance in DR Congo, as baseline for future assessments. Methods The search for this review was undertaken using the electronic databases PubMed and Google Scholar using the terms “malaria”, “Congo”, “resistance”, “molecular”, “antimalarial”, “efficacy”. Articles were classified based on year of collecting, year of publication, sample size and characteristics, molecular markers analysed and polymorphisms detected. Results Thirteen articles were included and five genes have been analysed in these studies: pfcrt, pfdhps, pfdhfr, pfmdr1 and K13-propeller. The majority of studies included were not representative of the whole country. Conclusion This systematic review demonstrates the lack of molecular resistance studies in DRC. Only 13 studies were identified in almost 15 years. The MOH must implement a national surveillance system for monitoring malaria drug resistance and this surveillance should be conducted frequently and country-representative.
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Affiliation(s)
- Dieudonné Makaba Mvumbi
- Biochemistry and Molecular Biology Unit, Department of Basic Sciences, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Jean-Marie Kayembe
- Department of Internal Medicine, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Hippolyte Situakibanza
- Department of Tropical Medicine and Infectious Disease, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Thierry L Bobanga
- Department of Tropical Medicine and Infectious Disease, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Célestin N Nsibu
- Department of Paediatric, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Georges L Mvumbi
- Biochemistry and Molecular Biology Unit, Department of Basic Sciences, School of Medicine, University of Kinshasa, Kinshasa, DR Congo.
| | - Pierrette Melin
- Department of Clinical Microbiology, University Hospital of Liège, Liège, Belgium.
| | - Patrick De Mol
- Department of Clinical Microbiology, University Hospital of Liège, Liège, Belgium.
| | - Marie-Pierre Hayette
- Department of Clinical Microbiology, University Hospital of Liège, Liège, Belgium.
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Takala-Harrison S, Laufer MK. Antimalarial drug resistance in Africa: key lessons for the future. Ann N Y Acad Sci 2015; 1342:62-7. [PMID: 25891142 DOI: 10.1111/nyas.12766] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Drug-resistant parasites repeatedly arise as a result of widespread use of antimalarial drugs and have contributed significantly to the failure to control and eradicate malaria throughout the world. In this review, we describe the spread of resistance to chloroquine and sulfadoxine-pyrimethamine, two old drugs that are no longer used owing to high rates of resistance, and examine the effect of the removal of drug pressure on the survival of resistant parasites. Artemisinin-resistant malaria is now emerging in Southeast Asia in a unique and unexpected pattern. We will review the most recent genomic and clinical data to help predict the behavior of resistance to new antimalarial medications and inform strategies to prevent the spread of drug-resistant malaria in Africa in the future.
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Affiliation(s)
- Shannon Takala-Harrison
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland
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