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Rosenthal PJ, Asua V, Conrad MD. Emergence, transmission dynamics and mechanisms of artemisinin partial resistance in malaria parasites in Africa. Nat Rev Microbiol 2024; 22:373-384. [PMID: 38321292 DOI: 10.1038/s41579-024-01008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
Malaria, mostly due to Plasmodium falciparum infection in Africa, remains one of the most important infectious diseases in the world. Standard treatment for uncomplicated P. falciparum malaria is artemisinin-based combination therapy (ACT), which includes a rapid-acting artemisinin derivative plus a longer-acting partner drug, and standard therapy for severe P. falciparum malaria is intravenous artesunate. The efficacy of artemisinins and ACT has been threatened by the emergence of artemisinin partial resistance in Southeast Asia, mediated principally by mutations in the P. falciparum Kelch 13 (K13) protein. High ACT treatment failure rates have occurred when resistance to partner drugs is also seen. Recently, artemisinin partial resistance has emerged in Rwanda, Uganda and the Horn of Africa, with independent emergences of different K13 mutants in each region. In this Review, we summarize our current knowledge of artemisinin partial resistance and focus on the emergence of resistance in Africa, including its epidemiology, transmission dynamics and mechanisms. At present, the clinical impact of emerging resistance in Africa is unclear and most available evidence suggests that the efficacies of leading ACTs remain excellent, but there is an urgent need to better appreciate the extent of the problem and its consequences for the treatment and control of malaria.
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Affiliation(s)
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda
- University of Tübingen, Tübingen, Germany
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Nain M, Dhorda M, Flegg JA, Gupta A, Harrison LE, Singh-Phulgenda S, Otienoburu SD, Harriss E, Bharti PK, Behera B, Rahi M, Guerin PJ, Sharma A. Systematic Review and Geospatial Modeling of Molecular Markers of Resistance to Artemisinins and Sulfadoxine-Pyrimethamine in Plasmodium falciparum in India. Am J Trop Med Hyg 2024; 110:910-920. [PMID: 38574550 PMCID: PMC11066343 DOI: 10.4269/ajtmh.23-0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/17/2023] [Indexed: 04/06/2024] Open
Abstract
Surveillance for genetic markers of resistance can provide valuable information on the likely efficacy of antimalarials but needs to be targeted to ensure optimal use of resources. We conducted a systematic search and review of publications in seven databases to compile resistance marker data from studies in India. The sample collection from the studies identified from this search was conducted between 1994 and 2020, and these studies were published between 1994 and 2022. In all, Plasmodium falciparum Kelch13 (PfK13), P. falciparum dihydropteroate synthase, and P. falciparum dihydrofolate reductase (PfDHPS) genotype data from 2,953, 4,148, and 4,222 blood samples from patients with laboratory-confirmed malaria, respectively, were extracted from these publications and uploaded onto the WorldWide Antimalarial Resistance Network molecular surveyors. These data were fed into hierarchical geostatistical models to produce maps with a predicted prevalence of the PfK13 and PfDHPS markers, and of the associated uncertainty. Zones with a predicted PfDHPS 540E prevalence of >15% were identified in central, eastern, and northeastern India. The predicted prevalence of PfK13 mutants was nonzero at only a few locations, but were within or adjacent to the zones with >15% prevalence of PfDHPS 540E. There may be a greater probability of artesunate-sulfadoxine-pyrimethamine failures in these regions, but these predictions need confirmation. This work can be applied in India and elsewhere to help identify the treatments most likely to be effective for malaria elimination.
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Affiliation(s)
- Minu Nain
- ICMR-National Institute of Malaria Research, New Delhi, India
| | - Mehul Dhorda
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Infectious Diseases Data Observatory, Oxford, United Kingdom
- 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, United Kingdom
| | - Jennifer A. Flegg
- School of Mathematics and Statistics, University of Melbourne, Parkville, Victoria, Australia
| | - Apoorv Gupta
- ICMR-National Institute of Malaria Research, New Delhi, India
| | - Lucinda E. Harrison
- School of Mathematics and Statistics, University of Melbourne, Parkville, Victoria, Australia
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sabina D. Otienoburu
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Infectious Diseases Data Observatory, Oxford, United Kingdom
- College of STEM, Johnson C. Smith University, Charlotte, North Carolina
| | - Eli Harriss
- The Knowledge Centre, Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | | | - Beauty Behera
- ICMR-National Institute of Malaria Research, New Delhi, India
| | - Manju Rahi
- ICMR-National Institute of Malaria Research, New Delhi, India
- Indian Council of Medical Research, New Delhi, India
- Academy of Scientific and Innovative Research, Ghaziabad, Uttar Pradesh
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Infectious Diseases Data Observatory, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Amit Sharma
- ICMR-National Institute of Malaria Research, New Delhi, India
- Molecular Medicine, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
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Rosenthal PJ, Asua V, Bailey JA, Conrad MD, Ishengoma DS, Kamya MR, Rasmussen C, Tadesse FG, Uwimana A, Fidock DA. The emergence of artemisinin partial resistance in Africa: how do we respond? THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00141-5. [PMID: 38552654 DOI: 10.1016/s1473-3099(24)00141-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 04/21/2024]
Abstract
Malaria remains one of the most important infectious diseases in the world, with the greatest burden in sub-Saharan Africa, primarily from Plasmodium falciparum infection. The treatment and control of malaria is challenged by resistance to most available drugs, but partial resistance to artemisinins (ART-R), the most important class for the treatment of malaria, was until recently confined to southeast Asia. This situation has changed, with the emergence of ART-R in multiple countries in eastern Africa. ART-R is mediated primarily by single point mutations in the P falciparum kelch13 protein, with several mutations present in African parasites that are now validated resistance mediators based on clinical and laboratory criteria. Major priorities at present are the expansion of genomic surveillance for ART-R mutations across the continent, more frequent testing of the efficacies of artemisinin-based regimens against uncomplicated and severe malaria in trials, more regular assessment of ex-vivo antimalarial drug susceptibilities, consideration of changes in treatment policy to deter the spread of ART-R, and accelerated development of new antimalarial regimens to overcome the impacts of ART-R. The emergence of ART-R in Africa is an urgent concern, and it is essential that we increase efforts to characterise its spread and mitigate its impact.
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Affiliation(s)
- Philip J Rosenthal
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda; University of Tübingen, Tübingen, Germany
| | - Jeffrey A Bailey
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA; Departments of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Melissa D Conrad
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania; Department of Biochemistry, Kampala International University in Tanzania, Dar es Salaam, Tanzania; School of Public Health, Harvard University, Boston, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Fitsum G Tadesse
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia; London School of Hygiene and Tropical Medicine, London, UK
| | - Aline Uwimana
- Rwanda Biomedical Center, Kigali, Rwanda; Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - David A Fidock
- Department of Microbiology and Immunology and Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Sinha A, Kar S, Chauhan C, Yadav CP, Kori L. Meta-analysis on Plasmodium falciparum sulfadoxine-pyrimethamine resistance-conferring mutations in India identifies hot spots for genetic surveillance. Int J Antimicrob Agents 2024; 63:107071. [PMID: 38154659 DOI: 10.1016/j.ijantimicag.2023.107071] [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: 07/27/2023] [Revised: 12/05/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND India is on track to eliminate malaria by 2030 but emerging resistance to first-line antimalarials is a recognised threat. Two instances of rapid development, spread, and natural selection of drug-resistant mutant parasites in India (chloroquine across the country and artesunate + sulfadoxine-pyrimethamine [AS+SP] in the northeastern states) translated into drug policy changes for Plasmodium falciparum malaria in 2010 and 2013, respectively. Considering these rapid changes in the SP drug resistance-conferring mutation profile of P. falciparum, there is a need to systematically monitor the validated mutations in Pfdhfr and Pfdhps genes across India alongside AS+SP therapeutic efficacy studies. There has been no robust, systematic countrywide surveillance reported for these parameters in India, hence the current study was undertaken. METHODS Studies that reported data on WHO-validated SP resistance markers in P. falciparum across India from 2008 to January 2023 were included. Five major databases, PubMedⓇ, Web of ScienceTM, ScopusⓇ, EmbaseⓇ, and Google Scholar, were exhaustively searched. Individual and pooled prevalence estimates of mutations were obtained through random- and fixed-effect models. Data were depicted using forest plots created with a 95% confidence interval. The study is registered with PROSPERO (CRD42021236012). RESULTS A total of 37 publications, and 533 Pfdhfr and 134 Pfdhps National Centre of Biotechnology Information (NCBI) DNA sequences were included from >4000 samples. The study included information from 80 districts, 21 states and 3 union territories (UTs) from India. The two PfDHFR mutations, C59R (62%) and S108N (74%), were the most prevalent mutations (pooled estimates 61% and 71%, respectively) and appeared to be stabilised/fixed. Although rarest overall, the prevalence of I164L was observed to be as high as 32%. The PfDHFR double mutants were the most prevalent overall (51%; pooled 42%). The prevalence of triple and quadruple mutations was 6% and 5%, respectively, and is an immediate concern for some states. The most prevalent PfDHPS mutation was A437G (39%), followed by K540E (25%) and A581G (12%). There was a low overall prevalence of PfDHFR/PfDHPS quintuple and sextuple mutations but surveillance for these mutations is critical for some areas. CONCLUSION The analyses span the two critical policy changes, highlight the areas of concern, and guide policymakers in strategising and refining the anti-malaria drug policy for malaria elimination. The results of the analyses also highlight the SP-resistance hot spots, critical gaps and challenges, and indicate that focal and local malaria genetic surveillance (including drug-resistance markers) is needed until malaria is successfully eliminated.
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Affiliation(s)
- Abhinav Sinha
- ICMR-National Institute of Malaria Research, New Delhi, India.
| | - Sonalika Kar
- ICMR-National Institute of Malaria Research, New Delhi, India
| | - Charu Chauhan
- ICMR-National Institute of Malaria Research, New Delhi, India
| | | | - Lokesh Kori
- ICMR-National Institute of Malaria Research, New Delhi, India
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Valecha N. Keeping the momentum: suggestions for treatment policy updates in the final push to eliminate malaria in India. Malar J 2023; 22:128. [PMID: 37072795 PMCID: PMC10114449 DOI: 10.1186/s12936-023-04558-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Malaria case management with prompt and effective treatment is critical to minimize morbidity and mortality, reduce transmission and to prevent the emergence and spread of anti-malarial drug resistance. India has the highest burden of malaria in South East Asia Region and has made impressive progress in the reduction of the malaria burden in recent years. Since the last revision to the Indian national malaria treatment policy in 2013, guidelines on new treatment strategies have been published for the control/ elimination of malaria by the World Health Organisation (WHO). The most recent update was in March 2023 based on the new evidence available. India's success is the Region's success. Therefore, to meet the national as well as regional targets of elimination, the Indian National Programme needs to consider WHO guidelines, deliberate with stakeholders and experts so as to tailor and adapt to the local context, and update National policies to incorporate the relevant ones. Technical aspects of new WHO guidelines which need to be considered for updating India's treatment policy are discussed.
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Chakrabarti R, Chery-Karschney L, White J, Mascarenhas A, Skillman KM, Kanjee U, Babar PH, Patrapuvich R, Mohapatra PK, Patankar S, Smith JD, Anvikar A, Valecha N, Rahi M, Duraisingh MT, Rathod PK. Diverse Malaria Presentations across National Institutes of Health South Asia International Center for Excellence in Malaria Research Sites in India. Am J Trop Med Hyg 2022; 107:107-117. [PMID: 36228910 PMCID: PMC9662227 DOI: 10.4269/ajtmh.21-1344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/14/2022] [Indexed: 11/07/2022] Open
Abstract
The Malaria Evolution in South Asia (MESA) International Center for Excellence in Malaria Research (ICEMR) was established by the US National Institutes of Health (US NIH) as one of 10 malaria research centers in endemic countries. In 10 years of hospital-based and field-based work in India, the MESA-ICEMR has documented the changing epidemiology and transmission of malaria in four different parts of India. Malaria Evolution in South Asia-ICEMR activities, in collaboration with Indian partners, are carried out in the broad thematic areas of malaria case surveillance, vector biology and transmission, antimalarial resistance, pathogenesis, and host response. The program integrates insights from surveillance and field studies with novel basic science studies. This is a two-pronged approach determining the biology behind the disease patterns seen in the field, and generating new relevant biological questions about malaria to be tested in the field. Malaria Evolution in South Asia-ICEMR activities inform local and international stakeholders on the current status of malaria transmission in select parts of South Asia including updates on regional vectors of transmission of local parasites. The community surveys and new laboratory tools help monitor ongoing efforts to control and eliminate malaria in key regions of South Asia including the state of evolving antimalarial resistance in different parts of India, new host biomarkers of recent infection, and molecular markers of pathogenesis from uncomplicated and severe malaria.
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Affiliation(s)
- Rimi Chakrabarti
- Department of Chemistry, University of Washington, Seattle, Washington
- Department of Medicine, Goa Medical College and Hospital, Bambolim, Goa, India
| | | | - John White
- Department of Chemistry, University of Washington, Seattle, Washington
| | - Anjali Mascarenhas
- Department of Chemistry, University of Washington, Seattle, Washington
- Department of Medicine, Goa Medical College and Hospital, Bambolim, Goa, India
| | - Kristen M. Skillman
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Usheer Kanjee
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Prasad H. Babar
- Department of Chemistry, University of Washington, Seattle, Washington
- Department of Medicine, Goa Medical College and Hospital, Bambolim, Goa, India
| | - Rapatbhorn Patrapuvich
- Drug Research Unit for Malaria (DRUM), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Swati Patankar
- Department of Biosciences and Bioengineering, IIT Bombay, Powai, Mumbai, India
| | | | - Anup Anvikar
- National Institute of Biologicals, Noida, UP, India
| | - Neena Valecha
- National Institute of Malaria Research, New Delhi, India
| | - Manju Rahi
- Division of Epidemiology and Communicable Disease, Indian Council of Medical Research, New Delhi, India
| | - Manoj T. Duraisingh
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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