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Singh-Phulgenda S, Kumar R, Dahal P, Munir A, Rashan S, Chhajed R, Naylor C, Maguire BJ, Siddiqui NA, Harriss E, Rahi M, Alves F, Sundar S, Stepniewska K, Musa A, Guerin PJ, Pandey K. Post-kala-azar dermal leishmaniasis (PKDL) drug efficacy study landscape: A systematic scoping review of clinical trials and observational studies to assess the feasibility of establishing an individual participant-level data (IPD) platform. PLoS Negl Trop Dis 2024; 18:e0011635. [PMID: 38626228 PMCID: PMC11051605 DOI: 10.1371/journal.pntd.0011635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/26/2024] [Accepted: 03/27/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis which can occur after successful treatment of visceral leishmaniasis (VL) and is a public health problem in VL endemic areas. We conducted a systematic scoping review to assess the characteristics of published PKDL clinical studies, understand the scope of research and explore the feasibility and value of developing a PKDL individual patient data (IPD) platform. METHODS A systematic review of published literature was conducted to identify PKDL clinical studies by searching the following databases: PubMed, Scopus, Ovid Embase, Web of Science Core Collection, WHO Global Index Medicus, PASCAL, Clinicaltrials.gov, Ovid Global Health, Cochrane Database and CENTRAL, and the WHO International Clinical Trials Registry Platform. Only prospective studies in humans with PKDL diagnosis, treatment, and follow-up measurements between January 1973 and March 2023 were included. Extracted data includes variables on patient characteristics, treatment regimens, diagnostic methods, geographical locations, efficacy endpoints, adverse events and statistical methodology. RESULTS A total of 3,418 records were screened, of which 56 unique studies (n = 2,486 patients) were included in this review. Out of the 56 studies, 36 (64.3%) were from India (1983-2022), 12 (21.4%) from Sudan (1992-2021), 6 (10.7%) were from Bangladesh (1991-2019), and 2 (3.6%) from Nepal (2001-2007). Five (8.9%) studies were published between 1981-1990 (n = 193 patients), 10 (17.9%) between 1991-2000 (n = 230 patients), 10 (17.9%) between 2001-2010 (n = 198 patients), and 31 (55.4%) from 2011 onwards (n = 1,865 patients). Eight (14.3%) were randomised clinical trials, and 48 (85.7%) were non-randomised studies. The median post-treatment follow-up duration was 365 days (range: 90-540 days) in 8 RCTs and 360 days (range: 28-2,373 days) in 48 non-randomised studies. Disease diagnosis was based on clinical criterion in 3 (5.4%) studies, a mixture of clinical and parasitological methods in 47 (83.9%) and was unclear in 6 (10.7%) studies. Major drugs used for treatment were miltefosine (n = 636 patients), liposomal amphotericin B (L-AmB) (n = 508 patients), and antinomy regimens (n = 454 patients). Ten other drug regimens were tested in 270 patients with less than 60 patients per regimen. CONCLUSIONS Our review identified studies with very limited sample size for the three major drugs (miltefosine, L-AmB, and pentavalent antimony), while the number of patients combined across studies suggest that the IPD platform would be valuable. With the support of relevant stakeholders, the global PKDL community and sufficient financing, a PKDL IPD platform can be realised. This will allow for exploration of different aspects of treatment safety and efficacy, which can potentially guide future healthcare decisions and clinical practices.
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Affiliation(s)
- Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rishikesh Kumar
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Abdalla Munir
- Department of Clinical Pathology and Immunology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Sumayyah Rashan
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rutuja Chhajed
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Caitlin Naylor
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Brittany J. Maguire
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Niyamat Ali Siddiqui
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
| | - Eli Harriss
- The Knowledge Centre, Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - Manju Rahi
- Indian Council of Medical Research (ICMR), New Delhi, India
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ahmed Musa
- Department of Clinical Pathology and Immunology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Philippe J. Guerin
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Krishna Pandey
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
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Stepniewska K, Allan R, Anvikar AR, Anyorigiya TA, Ashley EA, Bassat Q, Baudin E, Bjorkman A, Bonnet M, Boulton C, Bousema T, Carn G, Carrara VI, D'Alessandro U, Davis TME, Denoeud-Ndam L, Desai M, Djimde AA, Dorsey G, Etard JF, Falade C, Fanello C, Gaye O, Gonzalez R, Grandesso F, Grivoyannis AD, Grais RF, Humphreys GS, Ishengoma DS, Karema C, Kayentao K, Kennon K, Kremsner P, Laman M, Laminou IM, Macete E, Martensson A, Mayxay M, Menan HIB, Menéndez C, Moore BR, Nabasumba C, Ndiaye JL, Nhama A, Nosten F, Onyamboko M, Phyo AP, Ramharter M, Rosenthal PJ, Schramm B, Sharma YD, Sirima SB, Strub-Wourgaft N, Sylla K, Talisuna AO, Temu EA, Thwing JI, Tinto H, Valentini G, White NJ, Yeka A, Isanaka S, Barnes KI, Guerin PJ. Does acute malnutrition in young children increase the risk of treatment failure following artemisinin-based combination therapy? A WWARN individual patient data meta-analysis. Lancet Glob Health 2024; 12:e631-e640. [PMID: 38485430 PMCID: PMC10951956 DOI: 10.1016/s2214-109x(24)00003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The geographical, demographic, and socioeconomic distributions of malaria and malnutrition largely overlap. It remains unknown whether malnutrition affects the efficacy of WHO-recommended artemisinin-based combination therapies (ACTs). A previous systematic review was inconclusive as data were sparse and heterogeneous, indicating that other methodological approaches, such as individual patient data meta-analysis, should be considered. The objective of this study was to conduct such a meta-analysis to assess the effect of malnutrition (wasting and stunting) on treatment outcomes in children younger than 5 years treated with an ACT for uncomplicated falciparum malaria. METHODS We conducted a meta-analysis of individual patient data from studies identified through a systematic review of literature published between 1980 and 2018 in PubMed, Global Health, and Cochrane Libraries (PROSPERO CRD42017056934) and inspection of the WorldWide Antimalarial Resistance Network (WWARN) repository for ACT efficacy studies, including children younger than 5 years with uncomplicated falciparum malaria. The association of either acute (wasting) or chronic (stunting) malnutrition with day 42 PCR-adjusted risk of recrudescence (ie, return of the same infection) or reinfection after therapy was investigated using Cox regression, and with day 2 parasite positivity using logistic regression. FINDINGS Data were included from all 36 studies targeted, 31 from Africa. Of 11 301 eligible children in 75 study sites, 11·5% were wasted (weight-for-height Z score [WHZ] <-2), and 31·8% were stunted (height-for-age Z score [HAZ] <-2). Decrease in WHZ was associated with increased risk of day 2 positivity (adjusted odds ratio 1·12, 95% CI 1·05-1·18 per unit; p=0·0002), treatment failure (adjusted hazard ratio [AHR] 1·14, 95% CI 1·02-1·26, p=0·016), and reinfection after therapy (AHR 1·09, 1·04-1·13, p=0·0003). Children with milder wasting (WHZ -2 to -1) also had a higher risk of recrudescence (AHR 1·85, 1·29-2·65, p=0·0008 vs WHZ ≥0). Stunting was not associated with reduced ACT efficacy. INTERPRETATION Children younger than 5 years with acute malnutrition and presenting with uncomplicated falciparum malaria were at higher risk of delayed parasite clearance, ACT treatment failure, and reinfections. Stunting was more prevalent, but not associated with changes in ACT efficacy. Acute malnutrition is known to impact medicine absorption and metabolism. Further study to inform dose optimisation of ACTs in wasted children is urgently needed. FUNDING Bill & Melinda Gates Foundation. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Phiri KS, Khairallah C, Kwambai TK, Bojang K, Dhabangi A, Opoka R, Idro R, Stepniewska K, van Hensbroek MB, John CC, Robberstad B, Greenwood B, Kuile FOT. Post-discharge malaria chemoprevention in children admitted with severe anaemia in malaria-endemic settings in Africa: a systematic review and individual patient data meta-analysis of randomised controlled trials. Lancet Glob Health 2024; 12:e33-e44. [PMID: 38097295 PMCID: PMC10733130 DOI: 10.1016/s2214-109x(23)00492-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also have an increased risk of mortality or readmission after hospital discharge. We conducted a systematic review and individual patient data meta-analysis to determine the efficacy of monthly post-discharge malaria chemoprevention in children recovering from severe anaemia. METHODS This analysis was conducted according to PRISMA-IPD guidelines. We searched multiple databases on Aug 28, 2023, without date or language restrictions, for randomised controlled trials comparing monthly post-discharge malaria chemoprevention with placebo or standard of care among children (aged <15 years) admitted with severe anaemia in malaria-endemic Africa. Trials using daily or weekly malaria prophylaxis were not eligible. The investigators from all eligible trials shared pseudonymised datasets, which were standardised and merged for analysis. The primary outcome was all-cause mortality during the intervention period. Analyses were performed in the modified intention-to-treat population, including all randomly assigned participants who contributed to the endpoint. Fixed-effects two-stage meta-analysis of risk ratios (RRs) was used to generate pooled effect estimates for mortality. Recurrent time-to-event data (readmissions or clinic visits) were analysed using one-stage mixed-effects Prentice-Williams-Peterson total-time models to obtain hazard ratios (HRs). This study is registered with PROSPERO, CRD42022308791. FINDINGS Our search identified 91 articles, of which 78 were excluded by title and abstract, and a further ten did not meet eligibility criteria. Three double-blind, placebo-controlled trials, including 3663 children with severe anaemia, were included in the systematic review and meta-analysis; 3507 (95·7%) contributed to the modified intention-to-treat analysis. Participants received monthly sulfadoxine-pyrimethamine until the end of the malaria transmission season (mean 3·1 courses per child [range 1-6]; n=1085; The Gambia), monthly artemether-lumefantrine given at the end of weeks 4 and 8 post discharge (n=1373; Malawi), or monthly dihydroartemisinin-piperaquine given at the end of weeks 2, 6, and 10 post discharge (n=1049; Uganda and Kenya). During the intervention period, post-discharge malaria chemoprevention was associated with a 77% reduction in mortality (RR 0·23 [95% CI 0·08-0·70], p=0·0094, I2=0%) and a 55% reduction in all-cause readmissions (HR 0·45 [95% CI 0·36-0·56], p<0·0001) compared with placebo. The protective effect was restricted to the intervention period and was not sustained after the direct pharmacodynamic effect of the drugs had waned. The small number of trials limited our ability to assess heterogeneity, its sources, and publication bias. INTERPRETATION In malaria-endemic Africa, post-discharge malaria chemoprevention reduces mortality and readmissions in recently discharged children recovering from severe anaemia. Post-discharge malaria chemoprevention could be a valuable strategy for the management of this group at high risk. Future research should focus on methods of delivery, options to prolong the protection duration, other hospitalised groups at high risk, and interventions targeting non-malarial causes of post-discharge morbidity. FUNDING The Research-Council of Norway and the Bill-&-Melinda-Gates-Foundation through the Worldwide-Antimalarial-Research-Network.
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Affiliation(s)
- Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi; Training and Research Unit of Excellence, Blantyre, Malawi
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Titus K Kwambai
- Division of Parasitic Diseases and Malaria, Global Health Center, Centers for Disease Control and Prevention, Kisumu, Kenya; Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kalifa Bojang
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Aggrey Dhabangi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Makerere University College of Health Sciences, Kampala, Uganda; Aga Khan University, Medical College, Nairobi, Kenya
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Kasia Stepniewska
- Worldwide Antimalarial Resistance Network (WWARN), Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Michael Boele van Hensbroek
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bjarne Robberstad
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya.
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Munir A, Dahal P, Kumar R, Singh-Phulgenda S, Siddiqui NA, Naylor C, Wilson J, Buck G, Rahi M, Alves F, Malaviya P, Sundar S, Ritmeijer K, Stepniewska K, Pandey K, Guérin PJ, Musa A. Haematological dynamics following treatment of visceral leishmaniasis: a protocol for systematic review and individual participant data (IPD) meta-analysis. BMJ Open 2023; 13:e074841. [PMID: 38101841 PMCID: PMC10729213 DOI: 10.1136/bmjopen-2023-074841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/31/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Visceral leishmaniasis (VL) is a parasitic disease with an estimated 30 000 new cases occurring annually. Despite anaemia being a common haematological manifestation of VL, the evolution of different haematological characteristics following treatment remains poorly understood. An individual participant data meta-analysis (IPD-MA) is planned to characterise the haematological dynamics in patients with VL. METHODS AND ANALYSIS The Infectious Diseases Data Observatory (IDDO) VL data platform is a global repository of IPD from therapeutic studies identified through a systematic search of published literature (PROSPERO registration: CRD42021284622). The platform currently holds datasets from clinical trials standardised to a common data format. Corresponding authors and principal investigators of the studies indexed in the IDDO VL data platform meeting the eligibility criteria for inclusion were invited to be part of the collaborative IPD-MA. Mixed-effects multivariable regression models will be constructed to identify determinants of haematological parameters by taking clustering within study sites into account. ETHICS AND DISSEMINATION This IPD-MA meets the criteria for waiver of ethical review as defined by the Oxford Tropical Research Ethics Committee (OxTREC) granted to IDDO, as the research consists of secondary analysis of existing anonymised data (exempt granted on 29 March 2023, OxTREC REF: IDDO). Ethics approval was granted by the ICMR-Rajendra Memorial Research Institute of Medical Sciences ethics committee (letter no.: RMRI/EC/30/2022) on 4 July 2022. The results of this analysis will be disseminated at conferences, the IDDO website and peer-reviewed publications in open-access journals. The findings of this research will be critically important for control programmes at regional and global levels, policymakers and groups developing new VL treatments. PROSPERO REGISTRATION NUMBER CRD42021284622.
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Affiliation(s)
- Abdalla Munir
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rishikesh Kumar
- Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Caitlin Naylor
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James Wilson
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gemma Buck
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Manju Rahi
- Indian Council of Medical Research (ICMR), New Delhi, India
| | - Fabiana Alves
- Drugs for Neglected Disease Initiative, Geneva, Switzerland
| | - Paritosh Malaviya
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Krishna Pandey
- Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Philippe J Guérin
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
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Takyi A, Carrara VI, Dahal P, Przybylska M, Harriss E, Insaidoo G, Barnes KI, Guerin PJ, Stepniewska K. Characterisation of populations at risk of sub-optimal dosing of artemisinin-based combination therapy in Africa. PLOS Glob Public Health 2023; 3:e0002059. [PMID: 38039291 PMCID: PMC10691722 DOI: 10.1371/journal.pgph.0002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/25/2023] [Indexed: 12/03/2023]
Abstract
Selection of resistant malaria strains occurs when parasites are exposed to inadequate antimalarial drug concentrations. The proportion of uncomplicated falciparum malaria patients at risk of being sub-optimally dosed with the current World Health Organization (WHO) recommended artemisinin-based combination therapies (ACTs) is unknown. This study aims to estimate this proportion and the excess number of treatment failures (recrudescences) associated with sub-optimal dosing in Sub-Saharan Africa. Sub-populations at risk of sub-optimal dosing include wasted children <5 years of age, patients with hyperparasitaemia, pregnant women, people living with HIV, and overweight adults. Country-level data on population structure were extracted from openly accessible data sources. Pooled adjusted Hazard Ratios for PCR-confirmed recrudescence were estimated for each risk group from published meta-analyses using fixed-effect meta-analysis. In 2020, of the estimated 153.1 million uncomplicated P. falciparum malaria patients in Africa, the largest risk groups were the hyperparasitaemic patients (13.2 million, 8.6% of uncomplicated malaria cases) and overweight adults (10.3 million, 6.7% of uncomplicated cases). The estimated excess total number of treatment failures ranged from 0.338 million for a 98% baseline ACT efficacy to 1.352 million for a 92% baseline ACT efficacy. Our study shows that an estimated nearly 1 in 4 people with uncomplicated confirmed P. falciparum malaria in Africa are at risk of receiving a sub-optimal antimalarial drug dosing. This increases the risk of antimalarial drug resistance and poses a serious threat to malaria control and elimination efforts. Changes in antimalarial dosing or treatment duration of current antimalarials may be needed and new antimalarials development should ensure sufficient drug concentration levels in these sub-populations that carry a high malaria burden.
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Affiliation(s)
- Abena Takyi
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Department of Child Health, Korle Bu Teaching Hospital, Accra, Ghana
| | - Verena I. Carrara
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Prabin Dahal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
| | | | - Eli Harriss
- The Knowledge Centre, Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | | | - Karen I. Barnes
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Philippe J. Guerin
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
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Kumar R, Dahal P, Singh-Phulgenda S, Siddiqui NA, Munir A, Naylor C, Wilson J, Buck G, Rahi M, Malaviya P, Alves F, Sundar S, Ritmeijer K, Stepniewska K, Guérin PJ, Pandey K. Host, parasite and drug determinants of clinical outcomes following treatment of visceral leishmaniasis: a protocol for individual participant data meta-analysis. BMJ Open 2023; 13:e074679. [PMID: 37898487 PMCID: PMC10618999 DOI: 10.1136/bmjopen-2023-074679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/04/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Visceral leishmaniasis (VL) is a parasitic disease with an estimated 30 000 new cases occurring annually. There is an observed variation in the efficacy of the current first-line therapies across different regions. Such heterogeneity could be a function of host, parasite and drug factors. An individual participant data meta-analysis (IPD-MA) is planned to explore the determinants of treatment outcomes. METHODS AND ANALYSIS The Infectious Diseases Data Observatory (IDDO) VL living systematic review (IDDO VL LSR) library is an open-access resource of all published therapeutic studies in VL since 1980. For this current review, the search includes all clinical trials published between 1 January 1980 and 2 May 2021. Studies indexed in the IDDO VL LSR library were screened for eligibility for inclusion in this IPD-MA. Corresponding authors and principal investigators of the studies meeting the eligibility criteria for inclusion were invited to be part of the collaborative IPD-MA. Authors agreeing to participate in this collaborative research were requested to share the IPD using the IDDO VL data platform. The IDDO VL data platform currently holds data sets from clinical trials standardised to a common data format and provides a unique opportunity to identify host, parasite and drug determinants of treatment outcomes. Multivariable regression models will be constructed to identify determinants of therapeutic outcomes using generalised linear mixed-effects models accounting for within-study site clustering. ETHICS AND DISSEMINATION This IPD-MA meets the criteria for waiver of ethical review as defined by the Oxford Tropical Research Ethics Committee (OxTREC) granted to IDDO, as the research consists of secondary analysis of existing anonymised data (Exempt granted on 29 March 2023, OxTREC REF: IDDO) Ethics approval was granted by the ICMR-Rajendra Memorial Research Institute of Medical Sciences ethics committee (Letter no: RMRI/EC/30/2022) on 04-07-2022. The results of this IPD-MA will be disseminated at conferences, IDDO website and any peer-reviewed publications. All publications will be open source. Findings of this research will be critically important for the control programmes at regional/global levels, policy makers and groups developing new VL treatments. PROSPERO REGISTRATION CRD42021284622.
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Affiliation(s)
- Rishikesh Kumar
- Indian Council of Medical Research (ICMR)-Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Niyamat Ali Siddiqui
- Indian Council of Medical Research (ICMR)-Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Abdalla Munir
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Caitlin Naylor
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James Wilson
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gemma Buck
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Manju Rahi
- Epidemiology and Communicable Diseases, Indian Council of Medical Research (ICMR), New Delhi, Delhi, India
| | - Paritosh Malaviya
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Fabiana Alves
- Drugs for Neglected Disease Initiative, Geneva, Switzerland
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philippe J Guérin
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Krishna Pandey
- Indian Council of Medical Research (ICMR)-Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
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Wilson J, Chowdhury F, Hassan S, Harriss EK, Alves F, Dahal P, Stepniewska K, Guérin PJ. Prognostic prediction models for clinical outcomes in patients diagnosed with visceral leishmaniasis: protocol for a systematic review. BMJ Open 2023; 13:e075597. [PMID: 37879686 PMCID: PMC10603465 DOI: 10.1136/bmjopen-2023-075597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Visceral leishmaniasis (VL) is a neglected tropical disease responsible for many thousands of preventable deaths each year. Symptomatic patients often struggle to access effective treatment, without which death is the norm. Risk prediction tools support clinical teams and policymakers in identifying high-risk patients who could benefit from more intensive management pathways. Investigators interested in using their clinical data for prognostic research should first identify currently available models that are candidates for validation and possible updating. Addressing these needs, we aim to identify, summarise and appraise the available models predicting clinical outcomes in VL patients. METHODS AND ANALYSIS We will include studies that have developed, validated or updated prognostic models predicting future clinical outcomes in patients diagnosed with VL. Systematic reviews and meta-analyses that include eligible studies are also considered for review. Conference abstracts and educational theses are excluded. Data extraction, appraisal and reporting will follow current methodological guidelines. Ovid Embase; Ovid MEDLINE; the Web of Science Core Collection, SciELO and LILACS are searched from database inception to 1 March 2023 using terms developed for the identification of prediction models, and with no language restriction. Screening, data extraction and risk of bias assessment will be performed in duplicate with discordance resolved by a third independent reviewer. Risk of bias will be assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). Tables and figures will compare and contrast key model information, including source data, participants, model development and performance measures, and risk of bias. We will consider the strengths, limitations and clinical applicability of the identified models. ETHICS AND DISSEMINATION Ethics approval is not required for this review. The systematic review and all accompanying data will be submitted to an open-access journal. Findings will also be disseminated through the research group's website (www.iddo.org/research-themes/visceral-leishmaniasis) and social media channels. PROSPERO REGISTRATION NUMBER CRD42023417226.
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Affiliation(s)
- James Wilson
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Forhad Chowdhury
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Shermarke Hassan
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Elinor K Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Fabiana Alves
- Drugs for Neglected Disease Initiative, Geneva, Switzerland
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Philippe J Guérin
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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van Eijk AM, Stepniewska K, Hill J, Taylor SM, Rogerson SJ, Cottrell G, Chico RM, Gutman JR, Tinto H, Unger HW, Yanow SK, Meshnick SR, Ter Kuile FO, Mayor A. Prevalence of and risk factors for microscopic and submicroscopic malaria infections in pregnancy: a systematic review and meta-analysis. Lancet Glob Health 2023; 11:e1061-e1074. [PMID: 37276878 PMCID: PMC10880462 DOI: 10.1016/s2214-109x(23)00194-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Malaria infections during pregnancy can cause adverse birth outcomes, yet many infections are undetected by microscopy. We aimed to describe the epidemiology of submicroscopic malaria infections in pregnant women in Asia, the Americas, and Africa using aggregated and individual participant data (IPD). METHODS For this systematic review and meta-analysis, studies (published Jan 1, 1997 to Nov 10, 2021) with information on both microscopic and submicroscopic infections during pregnancy from Asia, the Americas, or Africa, identified in the Malaria-in-Pregnancy Library, were eligible. Studies (or subgroups or study groups) that selected participants on the basis of the presence of fever or a positive blood smear were excluded to avoid selection bias. We obtained IPD (when available) and aggregated data. Estimates of malaria transmission intensity and sulfadoxine-pyrimethamine resistance, matched by study location and year, were obtained using publicly available data. One-stage multivariable logit and multinomial models with random intercepts for study site were used in meta-analysis to assess prevalence of and risk factors for submicroscopic infections during pregnancy and at delivery. This study is registered with PROSPERO, number CRD42015027342. FINDINGS The search identified 87 eligible studies, 68 (78%) of which contributed to the analyses. Of these 68 studies, 45 (66%) studies contributed IPD (48 869 participants) and 23 (34%) studies contributed aggregated data (11 863 participants). During pregnancy, median prevalence estimates were 13·5% (range 0·0-55·9, 66 substudies) for submicroscopic and 8·0% (0·0-50·6, 66 substudies) for microscopic malaria. Among women with positive Plasmodium nucleic acid amplification tests (NAATs), the median proportion of submicroscopic infections was 58·7% (range 0·0-100); this proportion was highest in the Americas (73·3%, 0·0-100), followed by Asia (67·2%, 36·4-100) and Africa (56·5%, 20·5-97·7). In individual patient data analysis, compared with women with no malaria infections, those with submicroscopic infections were more likely to present with fever in Africa (adjusted odds ratio 1·32, 95% CI 1·02-1·72; p=0·038) but not in other regions. Among women with NAAT-positive infections in Asia and the Americas, Plasmodium vivax infections were more likely to be submicroscopic than Plasmodium falciparum infections (3·69, 2·45-5·54; p<0·0001). Risk factors for submicroscopic infections among women with NAAT-positive infections in Africa included older age (age ≥30 years), multigravidity, and no HIV infection. INTERPRETATION During pregnancy, submicroscopic infections are more common than microscopic infections and are associated with fever in Africa. Malaria control in pregnancy should target both microscopic and submicroscopic infections. FUNDING Bill & Melinda Gates Foundation through the Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Stephen J Rogerson
- Department of Infectious Diseases, Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia
| | | | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Sant-Unité de Recherche Clinique de Nanoro, Ouagadougou, Burkina Faso
| | - Holger W Unger
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Stephanie K Yanow
- School of Public Health, Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Steven R Meshnick
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alfredo Mayor
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
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Wynberg E, Commons RJ, Humphreys G, Ashurst H, Burrow R, Adjei GO, Adjuik M, Anstey NM, Anvikar A, Baird KJ, Barber BE, Barennes H, Baudin E, Bell DJ, Bethell D, Binh TQ, Borghini-Fuhrer I, Chu CS, Daher A, D’Alessandro U, Das D, Davis TME, de Vries PJ, Djimde AA, Dondorp AM, Dorsey G, Faucher JFF, Fogg C, Gaye O, Grigg M, Hatz C, Kager PA, Lacerda M, Laman M, Mårtensson A, Menan HIE, Monteiro WM, Moore BR, Nosten F, Ogutu B, Osorio L, Penali LK, Pereira DB, Rahim AG, Ramharter M, Sagara I, Schramm B, Seidlein L, Siqueira AM, Sirima SB, Starzengruber P, Sutanto I, Taylor WR, Toure OA, Utzinger J, Valea I, Valentini G, White NJ, William T, Woodrow CJ, Richmond CL, Guerin PJ, Price RN, Stepniewska K. Variability in white blood cell count during uncomplicated malaria and implications for parasite density estimation: a WorldWide Antimalarial Resistance Network individual patient data meta-analysis. Malar J 2023; 22:174. [PMID: 37280686 DOI: 10.1186/s12936-023-04583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends that when peripheral malarial parasitaemia is quantified by thick film microscopy, an actual white blood cell (WBC) count from a concurrently collected blood sample is used in calculations. However, in resource-limited settings an assumed WBC count is often used instead. The aim of this study was to describe the variability in WBC count during acute uncomplicated malaria, and estimate the impact of using an assumed value of WBC on estimates of parasite density and clearance. METHODS Uncomplicated malaria drug efficacy studies that measured WBC count were selected from the WorldWide Antimalarial Resistance Network data repository for an individual patient data meta-analysis of WBC counts. Regression models with random intercepts for study-site were used to assess WBC count variability at presentation and during follow-up. Inflation factors for parasitaemia density, and clearance estimates were calculated for methods using assumed WBC counts (8000 cells/µL and age-stratified values) using estimates derived from the measured WBC value as reference. RESULTS Eighty-four studies enrolling 27,656 patients with clinically uncomplicated malaria were included. Geometric mean WBC counts (× 1000 cells/µL) in age groups < 1, 1-4, 5-14 and ≥ 15 years were 10.5, 8.3, 7.1, 5.7 and 7.5, 7.0, 6.5, 6.0 for individuals with falciparum (n = 24,978) and vivax (n = 2678) malaria, respectively. At presentation, higher WBC counts were seen among patients with higher parasitaemia, severe anaemia and, for individuals with vivax malaria, in regions with shorter regional relapse periodicity. Among falciparum malaria patients, using an assumed WBC count of 8000 cells/µL resulted in parasite density underestimation by a median (IQR) of 26% (4-41%) in infants < 1 year old but an overestimation by 50% (16-91%) in adults aged ≥ 15 years. Use of age-stratified assumed WBC values removed systematic bias but did not improve precision of parasitaemia estimation. Imprecision of parasite clearance estimates was only affected by the within-patient WBC variability over time, and remained < 10% for 79% of patients. CONCLUSIONS Using an assumed WBC value for parasite density estimation from a thick smear may lead to underdiagnosis of hyperparasitaemia and could adversely affect clinical management; but does not result in clinically consequential inaccuracies in the estimation of the prevalence of prolonged parasite clearance and artemisinin resistance.
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Arena L, Zanamwe M, Halleux CM, Carrara V, Angus BJ, Ariana P, Humphreys GS, Richmond C, Stepniewska K, Guérin PJ, Olliaro PL. Malaria patient spectrum representation in therapeutic clinical trials of uncomplicated malaria: a scoping review of the literature. Malar J 2023; 22:50. [PMID: 36765317 PMCID: PMC9913008 DOI: 10.1186/s12936-023-04441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/03/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND For the results of clinical trials to have external validity, the patients included in the study must be representative of the population presenting in the general clinical settings. A scoping literature review was performed to evaluate how the eligibility criteria used in anti-malarial efficacy and safety trials translate into patient selection. METHODS A search of the WorldWide Antimalarial Resistance Network (WWARN) Clinical Trials Publication Library, MEDLINE, The Cochrane Library, and clinicaltrials.gov was conducted to identify trials investigating anti-malarial efficacy and safety, published between 14th April 2001 and 31st December 2017. An updated search using the WWARN Clinical Trial Publication Library was undertaken to identify eligible publications from 1st January 2018 to 31st July 2021. The review included studies in patients of any age with uncomplicated malaria and any pharmaceutical therapeutic intervention administered. The proportion of trials with malaria-positive patients excluded was calculated and linked to the reported reason for exclusion. A subgroup analysis on eligibility criteria and trial baseline demographics was conducted to assess whether criteria are complied with when recruiting patients. RESULTS Out of 847 studies, 176 (21%) trials were included in the final synthesis, screening a total of 157,516 malaria-positive patients, of whom 56,293 (36%) were enrolled and treated. Across the 176 studies included, 84 different inclusion and exclusion criteria were identified. The reason for exclusion of patients who tested positive for malaria was reported in 144 (82%) studies. Three criteria account for about 70% of malaria-positive patients excluded: mixed-species malaria infections or other specific Plasmodium species, parasite counts outside the set study ranges, and refusal of consent. CONCLUSIONS Nearly two-thirds of the malaria-positive subjects who present to health facilities are systematically excluded from anti-malarial treatment trials. Reasons for exclusions are largely under-reported. Anti-malarial treatment in the general population is informed by studies on a narrow selection of patients who do not fully represent the totality of those seeking antimalarial treatment in routine practice. While entry criteria ensure consistency across trials, pragmatic trials are also necessary to supplement the information currently available and improve the external validity of the findings of malaria clinical trials.
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Affiliation(s)
- Lorenzo Arena
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Mazvita Zanamwe
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christine M. Halleux
- grid.3575.40000000121633745Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization (WHO), Geneva, Switzerland
| | - Verena Carrara
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,grid.8591.50000 0001 2322 4988Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Brian J. Angus
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Proochista Ariana
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Georgina S. Humphreys
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Caitlin Richmond
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Kasia Stepniewska
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Philippe J. Guérin
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Piero L. Olliaro
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.4991.50000 0004 1936 8948ISARIC Global Support Centre, International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, UK
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Saito M, McGready R, Tinto H, Rouamba T, Mosha D, Rulisa S, Kariuki S, Desai M, Manyando C, Njunju EM, Sevene E, Vala A, Augusto O, Clerk C, Were E, Mrema S, Kisinza W, Byamugisha J, Kagawa M, Singlovic J, Yore M, van Eijk AM, Mehta U, Stergachis A, Hill J, Stepniewska K, Gomes M, Guérin PJ, Nosten F, Ter Kuile FO, Dellicour S. Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: a systematic review and individual patient data meta-analysis. Lancet 2023; 401:118-130. [PMID: 36442488 PMCID: PMC9874756 DOI: 10.1016/s0140-6736(22)01881-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. METHODS For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. FINDINGS We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92). INTERPRETATION We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted. FUNDING Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | - Stephen Rulisa
- School of Medicine and Pharmacy, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Eric M Njunju
- Department of Basic Sciences, Copperbelt University, Ndola, Zambia
| | - Esperanca Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique; Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | | | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | | | - William Kisinza
- National Institute of Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | - Mike Kagawa
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | | | - Mackensie Yore
- VA Los Angeles and University of California, Los Angeles National Clinician Scholars Program, VA Greater Los Angeles Healthcare System Health Services Research and Development Service Center of Innovation, Los Angeles, CA, USA
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, and Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Melba Gomes
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland; School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Feiko O Ter Kuile
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Jittamala P, Monteiro W, Smit MR, Pedrique B, Specht S, Chaccour CJ, Dard C, Giudice PD, Khieu V, Maruani A, Failoc-Rojas VE, Sáez-de-Ocariz M, Soriano-Arandes A, Piquero-Casals J, Faisant A, Brenier-Pinchart MP, Wimmersberger D, Coulibaly JT, Keiser J, Boralevi F, Sokana O, Marks M, Engelman D, Romani L, Steer AC, von Seidlein L, White NJ, Harriss E, Stepniewska K, Humphreys GS, Kennon K, Guerin PJ, Kobylinski KC. Correction: A systematic review and an individual patient data meta-analysis of ivermectin use in children weighing less than fifteen kilograms: Is it time to reconsider the current contraindication? PLoS Negl Trop Dis 2023; 17:e0011053. [PMID: 36607893 PMCID: PMC9821483 DOI: 10.1371/journal.pntd.0011053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pntd.0009144.].
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Stepniewska K, Allen EN, Humphreys GS, Poirot E, Craig E, Kennon K, Yilma D, Bousema T, Guerin PJ, White NJ, Price RN, Raman J, Martensson A, Mwaiswelo RO, Bancone G, Bastiaens GJH, Bjorkman A, Brown JM, D'Alessandro U, Dicko AA, El-Sayed B, Elzaki SE, Eziefula AC, Gonçalves BP, Hamid MMA, Kaneko A, Kariuki S, Khan W, Kwambai TK, Ley B, Ngasala BE, Nosten F, Okebe J, Samuels AM, Smit MR, Stone WJR, Sutanto I, Ter Kuile F, Tine RC, Tiono AB, Drakeley CJ, Gosling R, Stergachis A, Barnes KI, Chen I. Safety of single-dose primaquine as a Plasmodium falciparum gametocytocide: a systematic review and meta-analysis of individual patient data. BMC Med 2022; 20:350. [PMID: 36109733 PMCID: PMC9479278 DOI: 10.1186/s12916-022-02504-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/29/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In 2012, the World Health Organization (WHO) recommended single low-dose (SLD, 0.25 mg/kg) primaquine to be added as a Plasmodium (P.) falciparum gametocytocide to artemisinin-based combination therapy (ACT) without glucose-6-phosphate dehydrogenase (G6PD) testing, to accelerate malaria elimination efforts and avoid the spread of artemisinin resistance. Uptake of this recommendation has been relatively slow primarily due to safety concerns. METHODS A systematic review and individual patient data (IPD) meta-analysis of single-dose (SD) primaquine studies for P. falciparum malaria were performed. Absolute and fractional changes in haemoglobin concentration within a week and adverse effects within 28 days of treatment initiation were characterised and compared between primaquine and no primaquine arms using random intercept models. RESULTS Data comprised 20 studies that enrolled 6406 participants, of whom 5129 (80.1%) had received a single target dose of primaquine ranging between 0.0625 and 0.75 mg/kg. There was no effect of primaquine in G6PD-normal participants on haemoglobin concentrations. However, among 194 G6PD-deficient African participants, a 0.25 mg/kg primaquine target dose resulted in an additional 0.53 g/dL (95% CI 0.17-0.89) reduction in haemoglobin concentration by day 7, with a 0.27 (95% CI 0.19-0.34) g/dL haemoglobin drop estimated for every 0.1 mg/kg increase in primaquine dose. Baseline haemoglobin, young age, and hyperparasitaemia were the main determinants of becoming anaemic (Hb < 10 g/dL), with the nadir observed on ACT day 2 or 3, regardless of G6PD status and exposure to primaquine. Time to recovery from anaemia took longer in young children and those with baseline anaemia or hyperparasitaemia. Serious adverse haematological events after primaquine were few (9/3, 113, 0.3%) and transitory. One blood transfusion was reported in the primaquine arms, and there were no primaquine-related deaths. In controlled studies, the proportions with either haematological or any serious adverse event were similar between primaquine and no primaquine arms. CONCLUSIONS Our results support the WHO recommendation to use 0.25 mg/kg of primaquine as a P. falciparum gametocytocide, including in G6PD-deficient individuals. Although primaquine is associated with a transient reduction in haemoglobin levels in G6PD-deficient individuals, haemoglobin levels at clinical presentation are the major determinants of anaemia in these patients. TRIAL REGISTRATION PROSPERO, CRD42019128185.
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Affiliation(s)
- Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Elizabeth N Allen
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
| | - Eugenie Poirot
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
| | - Elaine Craig
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Daniel Yilma
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Jimma University Clinical Trial Unit, Department of Internal Medicine, Jimma University, Jimma, Ethiopia
| | - Teun Bousema
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Jaishree Raman
- Parasitology Reference Laboratory, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, Johannesburg, South Africa
- Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Andreas Martensson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Richard O Mwaiswelo
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Microbiology, Immunology and Parasitology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Germana Bancone
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Guido J H Bastiaens
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Laboratory of Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Anders Bjorkman
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Joelle M Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Umberto D'Alessandro
- Medical Research Council Unit, London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Alassane A Dicko
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Badria El-Sayed
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Salah-Eldin Elzaki
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Alice C Eziefula
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Bronner P Gonçalves
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Akira Kaneko
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Kisian, Kenya
| | - Wasif Khan
- Infectious Disease Division, International Centre for Diarrheal Diseases Research, Dhaka, Bangladesh
| | - Titus K Kwambai
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Billy E Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Joseph Okebe
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aaron M Samuels
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Menno R Smit
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Will J R Stone
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Depok City, Indonesia
| | | | - Roger C Tine
- Department of Medical Parasitology, Faculty of Medicine, University Cheikh Anta Diop, Dakar, Senegal
| | - Alfred B Tiono
- Department of Biomedical Sciences, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Chris J Drakeley
- Department of Infection Biology, London School of Tropical Medicine and Hygiene, London, UK
| | - Roly Gosling
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Andy Stergachis
- Departments of Pharmacy & Global Health, Schools of Pharmacy and Public Health, University of Washington, Seattle, USA
| | - Karen I Barnes
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ingrid Chen
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
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14
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Roberts T, Dahal P, Shrestha P, Schilling W, Shrestha R, Ngu R, Huong VTL, van Doorn HR, Phimolsarnnousith V, Miliya T, Crump JA, Bell D, Newton PN, Dittrich S, Hopkins H, Stepniewska K, Guerin PJ, Ashley EA, Turner P. Antimicrobial resistance patterns in bacteria causing febrile illness in Africa, South Asia, and Southeast Asia: a systematic review of published etiological studies from 1980-2015. Int J Infect Dis 2022; 122:612-621. [PMID: 35817284 DOI: 10.1016/j.ijid.2022.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE In this study, we aimed to conduct a systematic review to characterize antimicrobial resistance (AMR) patterns for bacterial causes of febrile illness in Africa and Asia. METHODS We included published literature from 1980-2015 based on data extracted from two recent systematic reviews of nonmalarial febrile illness from Africa, South Asia, and Southeast Asia. Selection criteria included articles with full bacterial identification and antimicrobial susceptibility testing (AST) results for key normally sterile site pathogen-drug combinations. Pooled proportions of resistant isolates were combined using random effects meta-analysis. Study data quality was graded using the Microbiology Investigation Criteria for Reporting Objectively (MICRO) framework. RESULTS Of 3475 unique articles included in the previous reviews, 371 included the target pathogen-drug combinations. Salmonella enterica tested against ceftriaxone and ciprofloxacin were the two highest reported combinations (30,509 and 22,056 isolates, respectively). Pooled proportions of resistant isolates were high for third-generation cephalosporins for Klebsiella pneumoniae and Escherichia coli in all regions. The MICRO grading showed an overall lack of standardization. CONCLUSION This review highlights a general increase in AMR reporting and in resistance over time. However, there were substantial problems with diagnostic microbiological data quality. Urgent strengthening of laboratory capacity, standardized testing, and reporting of AST results is required to improve AMR surveillance.
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Affiliation(s)
- Tamalee Roberts
- Lao-Oxford-Mahosot Hospital, Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Prabin Dahal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | - Poojan Shrestha
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | - William Schilling
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rujan Shrestha
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | - Roland Ngu
- Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | | | - H Rogier van Doorn
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Clinical Research Unit (OUCRU), Vietnam
| | - Vilayouth Phimolsarnnousith
- Lao-Oxford-Mahosot Hospital, Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - John A Crump
- Centre for International Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - David Bell
- Independent consultant, Issaquah, WA, USA
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital, Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK; London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | - Philippe J Guerin
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), University of Oxford, Old Road Campus, Oxford, UK
| | - Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital, Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
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15
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Das D, Vongpromek R, Assawariyathipat T, Srinamon K, Kennon K, Stepniewska K, Ghose A, Sayeed AA, Faiz MA, Netto RLA, Siqueira A, Yerbanga SR, Ouédraogo JB, Callery JJ, Peto TJ, Tripura R, Koukouikila-Koussounda F, Ntoumi F, Ong’echa JM, Ogutu B, Ghimire P, Marfurt J, Ley B, Seck A, Ndiaye M, Moodley B, Sun LM, Archasuksan L, Proux S, Nsobya SL, Rosenthal PJ, Horning MP, McGuire SK, Mehanian C, Burkot S, Delahunt CB, Bachman C, Price RN, Dondorp AM, Chappuis F, Guérin PJ, Dhorda M. Field evaluation of the diagnostic performance of EasyScan GO: a digital malaria microscopy device based on machine-learning. Malar J 2022; 21:122. [PMID: 35413904 PMCID: PMC9004086 DOI: 10.1186/s12936-022-04146-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 03/30/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Microscopic examination of Giemsa-stained blood films remains the reference standard for malaria parasite detection and quantification, but is undermined by difficulties in ensuring high-quality manual reading and inter-reader reliability. Automated parasite detection and quantification may address this issue. METHODS A multi-centre, observational study was conducted during 2018 and 2019 at 11 sites to assess the performance of the EasyScan Go, a microscopy device employing machine-learning-based image analysis. Sensitivity, specificity, accuracy of species detection and parasite density estimation were assessed with expert microscopy as the reference. Intra- and inter-device reliability of the device was also evaluated by comparing results from repeat reads on the same and two different devices. This study has been reported in accordance with the Standards for Reporting Diagnostic accuracy studies (STARD) checklist. RESULTS In total, 2250 Giemsa-stained blood films were prepared and read independently by expert microscopists and the EasyScan Go device. The diagnostic sensitivity of EasyScan Go was 91.1% (95% CI 88.9-92.7), and specificity 75.6% (95% CI 73.1-78.0). With good quality slides sensitivity was similar (89.1%, 95%CI 86.2-91.5), but specificity increased to 85.1% (95%CI 82.6-87.4). Sensitivity increased with parasitaemia rising from 57% at < 200 parasite/µL, to ≥ 90% at > 200-200,000 parasite/µL. Species were identified accurately in 93% of Plasmodium falciparum samples (kappa = 0.76, 95% CI 0.69-0.83), and in 92% of Plasmodium vivax samples (kappa = 0.73, 95% CI 0.66-0.80). Parasite density estimates by the EasyScan Go were within ± 25% of the microscopic reference counts in 23% of slides. CONCLUSIONS The performance of the EasyScan Go in parasite detection and species identification accuracy fulfil WHO-TDR Research Malaria Microscopy competence level 2 criteria. In terms of parasite quantification and false positive rate, it meets the level 4 WHO-TDR Research Malaria Microscopy criteria. All performance parameters were significantly affected by slide quality. Further software improvement is required to improve sensitivity at low parasitaemia and parasite density estimations. Trial registration ClinicalTrials.gov number NCT03512678.
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Affiliation(s)
- Debashish Das
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.8591.50000 0001 2322 4988Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Ranitha Vongpromek
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Thanawat Assawariyathipat
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Ketsanee Srinamon
- grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Kalynn Kennon
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Aniruddha Ghose
- grid.414267.20000 0004 5929 0882Chittagong Medical College (CMC), Chattogram, Bangladesh
| | - Abdullah Abu Sayeed
- grid.414267.20000 0004 5929 0882Chittagong Medical College (CMC), Chattogram, Bangladesh
| | | | - Rebeca Linhares Abreu Netto
- grid.418153.a0000 0004 0486 0972Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Amazonas Brazil
| | - Andre Siqueira
- grid.418068.30000 0001 0723 0931Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Serge R. Yerbanga
- Institut Des Sciences Et Techniques (INSTech), Bobo-Dioulasso, Burkina Faso
| | | | - James J. Callery
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Thomas J. Peto
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Rupam Tripura
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | | | - Francine Ntoumi
- grid.452468.90000 0004 7672 9850Fondation Congolaise Pour La Recherche Médicale (FCRM), Brazzaville, Congo
| | - John Michael Ong’echa
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Bernhards Ogutu
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Prakash Ghimire
- grid.80817.360000 0001 2114 6728Tribhuvan University, Kathmandu, Nepal
| | - Jutta Marfurt
- grid.1043.60000 0001 2157 559XGlobal and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT Australia
| | - Benedikt Ley
- grid.1043.60000 0001 2157 559XGlobal and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT Australia
| | - Amadou Seck
- grid.8191.10000 0001 2186 9619Faculty of Medicine, University Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Magatte Ndiaye
- grid.8191.10000 0001 2186 9619Faculty of Medicine, University Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Bhavani Moodley
- grid.416657.70000 0004 0630 4574Parasitology Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lisa Ming Sun
- grid.416657.70000 0004 0630 4574Parasitology Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Laypaw Archasuksan
- grid.10223.320000 0004 1937 0490Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Stephane Proux
- grid.10223.320000 0004 1937 0490Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Sam L. Nsobya
- grid.11194.3c0000 0004 0620 0548Department of Pathology, College of Health Science, Makerere University, Kampala, Uganda ,grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Philip J. Rosenthal
- grid.266102.10000 0001 2297 6811University of California, San Francisco, CA USA
| | | | | | - Courosh Mehanian
- Global Health Labs, Bellevue, WA USA ,grid.170202.60000 0004 1936 8008University of Oregon, Eugene, OR USA
| | | | | | | | - Ric N. Price
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ,grid.1043.60000 0001 2157 559XGlobal and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT Australia
| | - Arjen M. Dondorp
- grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - François Chappuis
- grid.150338.c0000 0001 0721 9812Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Philippe J. Guérin
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mehul Dhorda
- grid.499581.8Infectious Diseases Data Observatory (IDDO), Oxford, UK ,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK ,grid.501272.30000 0004 5936 4917Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
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Mansoor R, Commons RJ, Douglas NM, Abuaku B, Achan J, Adam I, Adjei GO, Adjuik M, Alemayehu BH, Allan R, Allen EN, Anvikar AR, Arinaitwe E, Ashley EA, Ashurst H, Asih PBS, Bakyaita N, Barennes H, Barnes KI, Basco L, Bassat Q, Baudin E, Bell DJ, Bethell D, Bjorkman A, Boulton C, Bousema T, Brasseur P, Bukirwa H, Burrow R, Carrara VI, Cot M, D’Alessandro U, Das D, Das S, Davis TME, Desai M, Djimde AA, Dondorp AM, Dorsey G, Drakeley CJ, Duparc S, Espié E, Etard JF, Falade C, Faucher JF, Filler S, Fogg C, Fukuda M, Gaye O, Genton B, Ghulam Rahim A, Gilayeneh J, Gonzalez R, Grais RF, Grandesso F, Greenwood B, Grivoyannis A, Hatz C, Hodel EM, Humphreys GS, Hwang J, Ishengoma D, Juma E, Kachur SP, Kager PA, Kamugisha E, Kamya MR, Karema C, Kayentao K, Kazienga A, Kiechel JR, Kofoed PE, Koram K, Kremsner PG, Lalloo DG, Laman M, Lee SJ, Lell B, Maiga AW, Mårtensson A, Mayxay M, Mbacham W, McGready R, Menan H, Ménard D, Mockenhaupt F, Moore BR, Müller O, Nahum A, Ndiaye JL, Newton PN, Ngasala BE, Nikiema F, Nji AM, Noedl H, Nosten F, Ogutu BR, Ojurongbe O, Osorio L, Ouédraogo JB, Owusu-Agyei S, Pareek A, Penali LK, Piola P, Plucinski M, Premji Z, Ramharter M, Richmond CL, Rombo L, Roper C, Rosenthal PJ, Salman S, Same-Ekobo A, Sibley C, Sirima SB, Smithuis FM, Somé FA, Staedke SG, Starzengruber P, Strub-Wourgaft N, Sutanto I, Swarthout TD, Syafruddin D, Talisuna AO, Taylor WR, Temu EA, Thwing JI, Tinto H, Tjitra E, Touré OA, Tran TH, Ursing J, Valea I, Valentini G, van Vugt M, von Seidlein L, Ward SA, Were V, White NJ, Woodrow CJ, Yavo W, Yeka A, Zongo I, Simpson JA, Guerin PJ, Stepniewska K, Price RN. Haematological consequences of acute uncomplicated falciparum malaria: a WorldWide Antimalarial Resistance Network pooled analysis of individual patient data. BMC Med 2022; 20:85. [PMID: 35249546 PMCID: PMC8900374 DOI: 10.1186/s12916-022-02265-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/18/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Plasmodium falciparum malaria is associated with anaemia-related morbidity, attributable to host, parasite and drug factors. We quantified the haematological response following treatment of uncomplicated P. falciparum malaria to identify the factors associated with malarial anaemia. METHODS Individual patient data from eligible antimalarial efficacy studies of uncomplicated P. falciparum malaria, available through the WorldWide Antimalarial Resistance Network data repository prior to August 2015, were pooled using standardised methodology. The haematological response over time was quantified using a multivariable linear mixed effects model with nonlinear terms for time, and the model was then used to estimate the mean haemoglobin at day of nadir and day 7. Multivariable logistic regression quantified risk factors for moderately severe anaemia (haemoglobin < 7 g/dL) at day 0, day 3 and day 7 as well as a fractional fall ≥ 25% at day 3 and day 7. RESULTS A total of 70,226 patients, recruited into 200 studies between 1991 and 2013, were included in the analysis: 50,859 (72.4%) enrolled in Africa, 18,451 (26.3%) in Asia and 916 (1.3%) in South America. The median haemoglobin concentration at presentation was 9.9 g/dL (range 5.0-19.7 g/dL) in Africa, 11.6 g/dL (range 5.0-20.0 g/dL) in Asia and 12.3 g/dL (range 6.9-17.9 g/dL) in South America. Moderately severe anaemia (Hb < 7g/dl) was present in 8.4% (4284/50,859) of patients from Africa, 3.3% (606/18,451) from Asia and 0.1% (1/916) from South America. The nadir haemoglobin occurred on day 2 post treatment with a mean fall from baseline of 0.57 g/dL in Africa and 1.13 g/dL in Asia. Independent risk factors for moderately severe anaemia on day 7, in both Africa and Asia, included moderately severe anaemia at baseline (adjusted odds ratio (AOR) = 16.10 and AOR = 23.00, respectively), young age (age < 1 compared to ≥ 12 years AOR = 12.81 and AOR = 6.79, respectively), high parasitaemia (AOR = 1.78 and AOR = 1.58, respectively) and delayed parasite clearance (AOR = 2.44 and AOR = 2.59, respectively). In Asia, patients treated with an artemisinin-based regimen were at significantly greater risk of moderately severe anaemia on day 7 compared to those treated with a non-artemisinin-based regimen (AOR = 2.06 [95%CI 1.39-3.05], p < 0.001). CONCLUSIONS In patients with uncomplicated P. falciparum malaria, the nadir haemoglobin occurs 2 days after starting treatment. Although artemisinin-based treatments increase the rate of parasite clearance, in Asia they are associated with a greater risk of anaemia during recovery.
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17
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Amboko B, Stepniewska K, Machini B, Bejon P, Snow RW, Zurovac D. Factors influencing health workers' compliance with outpatient malaria 'test and treat' guidelines during the plateauing performance phase in Kenya, 2014-2016. Malar J 2022; 21:68. [PMID: 35241074 PMCID: PMC8895910 DOI: 10.1186/s12936-022-04093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background Health workers’ compliance with outpatient malaria ‘test and treat’ guidelines has improved since 2010 but plateaued from 2014 at suboptimal levels in Kenya. This study examined the factors associated with high but suboptimal compliance levels at facilities with available malaria tests and drugs. Methods Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65–69%) and no anti-malarial treatment for test negative patients (SR: 90–92%) were examined using multilevel logistic regression models. Results A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3–27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7–9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2–3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2–10.6); health workers’ perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8–5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2–2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1–3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5–0.9), a rash (aOR = 0.32; 95% CI: 0.2–0.7) or a running nose (aOR = 0.59; 95% CI: 0.4–0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers’ age, and correct knowledge of the targeted treatment policy. Conclusions To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of ‘test and treat’ commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers’ knowledge about malaria testing criteria considering their perceptions of endemicity. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04093-x.
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Affiliation(s)
- Beatrice Amboko
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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18
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Sondo P, Tahita MC, Ilboudo H, Rouamba T, Derra K, Tougri G, Ouédraogo F, Konseibo BMA, Roamba E, Otienoburu SD, Kaboré B, Kennon K, Ouédraogo K, Zongo WTNAR, Bocoum FY, Stepniewska K, Dhorda M, Guérin PJ, Tinto H. Boosting the impact of seasonal malaria chemoprevention (SMC) through simultaneous screening and treatment of household members of children receiving SMC in Burkina Faso: a protocol for a randomized open label trial. Arch Public Health 2022; 80:41. [PMID: 35081964 PMCID: PMC8791765 DOI: 10.1186/s13690-022-00800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Plasmodium falciparum malaria remains a major public health concern in sub-Sahara Africa. Seasonal malaria chemoprevention (SMC) with amodiaquine + sulfadoxine-pyrimethamine is one of the most important preventive interventions. Despite its implementation, the burden of malaria is still very high in children under five years old in Burkina Faso, suggesting that the expected impact of this promising strategy might not be attained. Development of innovative strategies to improve the efficacy of these existing malaria control measures is essential. In such context, we postulate that screening and treatment of malaria in household members of children receiving SMC could greatly improve the impact of SMC intervention and reduce malaria transmission in endemic settings. METHODS This randomized superiority trial will be carried out in the Nanoro health district, Burkina Faso. The unit of randomisation will be the household and all eligible children from a household will be allocated to the same study group. Households with 3-59 months old children will be assigned to either (i) control group (SMC alone) or (ii) intervention (SMC+ screening of household members with standard Histidin Rich Protein Rapid Diagnostic Test (HRP2-RDT) and treatment if positive). The sample size will be 526 isolated households per arm, i.e., around 1052 children under SMC coverage and an expected 1315 household members. Included children will be followed-up for 24 months to fully cover two consecutive malaria transmission seasons and two SMC cycles. Children will be actively followed-up during the malaria transmission seasons while in the dry seasons the follow-up will be passive. CONCLUSION The study will respond to a major public health concern by providing evidence of the efficacy of an innovative strategy to boost the impact of SMC intervention.
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Affiliation(s)
- Paul Sondo
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso.
| | - Marc Christian Tahita
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Hamidou Ilboudo
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Karim Derra
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Gauthier Tougri
- Ministry of health of Burkina Faso, National Malaria Control Program, Ouagadougou, Burkina Faso
| | - Florence Ouédraogo
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | | | - Eli Roamba
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Sabina Dahlström Otienoburu
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,College of STEM, Johnson C. Smith University, Charlotte, North Carolina, USA
| | - Bérenger Kaboré
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Kalynn Kennon
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Kadija Ouédraogo
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | | | - Fadima Yaya Bocoum
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mehul Dhorda
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philippe J Guérin
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Halidou Tinto
- Intitut de Recherche en Siences de la Santé (IRSS), Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
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McLean AR, Rashan S, Tran L, Arena L, Lawal A, Maguire BJ, Adele S, Antonio ES, Brack M, Caldwell F, Carrara VI, Charles R, Citarella BW, Epie TB, Feteh VF, Kennon K, Makuka GJ, Ngu R, Nwosu AP, Obiesie S, Ogbonnaa-Njoku C, Paul P, Richmond C, Singh-Phulgenda S, Strudwick S, Tyrrell CS, Stepniewska K, Strub-Wourgaft N, White NJ, Guérin PJ. The fragmented COVID-19 therapeutics research landscape: a living systematic review of clinical trial registrations evaluating priority pharmacological interventions. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17284.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: Many available medicines have been evaluated as potential repurposed treatments for coronavirus disease 2019 (COVID-19). We summarise the registered study landscape for 32 priority pharmacological treatments identified following consultation with external experts of the COVID-19 Clinical Research Coalition. Methods: All eligible trial registry records identified by systematic searches of the World Health Organisation International Clinical Trials Registry Platform as of 26th May 2021 were reviewed and extracted. A descriptive summary of study characteristics was performed. Results: We identified 1,314 registered studies that included at least one of the 32 priority pharmacological interventions. The majority (1,043, 79%) were randomised controlled trials (RCTs). The sample size of the RCTs identified was typically small (median (25th, 75th percentile) sample size = 140 patients (70, 383)), i.e. individually powered only to show very large effects. The most extensively evaluated medicine was hydroxychloroquine (418 registered studies). Other widely studied interventions were convalescent plasma (n=208), ritonavir (n=189) usually combined with lopinavir (n=181), and azithromycin (n=147). Very few RCTs planned to recruit participants in low-income countries (n=14; 1.3%). A minority of studies (348, 26%) indicated a willingness to share individual participant data. The living systematic review data are available at https://iddo.cognitive.city Conclusions: There are many registered studies planning to evaluate available medicines as potential repurposed treatments of COVID-19. Most of these planned studies are small, and therefore substantially underpowered for most relevant endpoints. Very few are large enough to have any chance of providing enough convincing evidence to change policies and practices. The sharing of individual participant data (IPD) from these studies would allow pooled IPD meta-analyses which could generate definitive conclusions, but most registered studies did not indicate that they were willing to share their data.
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20
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Amboko B, Stepniewska K, Malla L, Machini B, Bejon P, Snow RW, Zurovac D. Determinants of improvement trends in health workers' compliance with outpatient malaria case-management guidelines at health facilities with available "test and treat" commodities in Kenya. PLoS One 2021; 16:e0259020. [PMID: 34739519 PMCID: PMC8570506 DOI: 10.1371/journal.pone.0259020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Health workers' compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements. METHODS Data from 11 national, cross-sectional health facility surveys undertaken from 2010-2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR). RESULTS Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite "test and treat" performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p<0.001) and highland epidemic (T-aOR = 1.35; p<0.001) zones compared to low-risk zone; with facilities stocking rapid diagnostic tests only (T-aOR = 1.49; p<0.001) compared to microscopy only services; with faith-based/non-governmental facilities compared to government-owned (T-aOR = 1.15; p = 0.036); with a daily caseload of >25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the "test and treat" policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers' gender, correct health workers' knowledge about the targeted malaria treatment policy, and patients' main complaint of fever. The odds of compliance at the baseline were variable for some of the factors. CONCLUSIONS Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers' knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.
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Affiliation(s)
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Robert W. Snow
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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21
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Gutman JR, Khairallah C, Stepniewska K, Tagbor H, Madanitsa M, Cairns M, L'lanziva AJ, Kalilani L, Otieno K, Mwapasa V, Meshnick S, Kariuki S, Chandramohan D, Desai M, Taylor SM, Greenwood B, ter Kuile FO. Intermittent screening and treatment with artemisinin-combination therapy versus intermittent preventive treatment with sulphadoxine-pyrimethamine for malaria in pregnancy: a systematic review and individual participant data meta-analysis of randomised clinical trials. EClinicalMedicine 2021; 41:101160. [PMID: 34746720 PMCID: PMC8556518 DOI: 10.1016/j.eclinm.2021.101160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 09/30/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, the efficacy of intermittent preventive therapy in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) for malaria in pregnancy is threatened by parasite resistance. We conducted an individual-participant data (IPD) meta-analysis to assess the efficacy of intermittent screening with malaria rapid diagnostic tests (RDTs) and treatment of RDT-positive women with artemisinin-based combination therapy (ISTp-ACT) compared to IPTp-SP, and understand the importance of subpatent infections. METHODS We searched MEDLINE and the Malaria-in-Pregnancy Library on May 6, 2021 for trials comparing ISTp-ACT and IPTp-SP. Generalised linear regression was used to compare adverse pregnancy outcomes (composite of small-for-gestational-age, low birthweight (LBW), or preterm delivery) and peripheral or placental Plasmodium falciparum at delivery. The effects of subpatent (PCR-positive, RDT/microscopy-negative) infections were assessed in both arms pooled using multi-variable fixed-effect models adjusting for the number of patent infections. PROSPERO registration: CRD42016043789. FINDINGS Five trials conducted between 2007 and 2014 contributed (10,821 pregnancies), two from high SP-resistance areas where dhfr/dhps quintuple mutant parasites are saturated, but sextuple mutants are still rare (Kenya and Malawi), and three from low-resistance areas (West-Africa). Four trials contributed IPD data (N=10,362). At delivery, the prevalence of any malaria infection (relative risk [RR]=1.08, 95% CI 1.00-1.16, I2=67.0 %) and patent infection (RR=1.02, 0.61-1.16, I2=0.0%) were similar. Subpatent infections were more common in ISTp recipients (RR=1.31, 1.05-1.62, I2=0.0%). There was no difference in adverse pregnancy outcome (RR=1.00, 0.96-1.05; studies=4, N=9,191, I2=54.5%). Subpatent infections were associated with LBW (adjusted RR=1.13, 1.07-1.19), lower mean birthweight (adjusted mean difference=32g, 15-49), and preterm delivery (aRR=1.35, 1.15-1.57). INTERPRETATION ISTp-ACT was not superior to IPTp-SP and may result in more subpatent infections than the existing IPTp-SP policy. Subpatent infections were associated with increased LBW and preterm delivery. More sensitive diagnostic tests are needed to detect and treat low-grade infections. FUNDING Centers for Disease Control and Prevention and Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Harry Tagbor
- University of Health and Allied Science, Ho, Ghana
| | | | | | - Anne Joan L'lanziva
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Linda Kalilani
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steve Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Steve M. Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
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22
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Das D, Dahal P, Dhorda M, Citarella BW, Kennon K, Stepniewska K, Felger I, Chappuis F, Guerin PJ. A Systematic Literature Review of Microscopy Methods Reported in Malaria Clinical Trials. Am J Trop Med Hyg 2020; 104:836-841. [PMID: 33350371 PMCID: PMC7941839 DOI: 10.4269/ajtmh.20-1219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/21/2020] [Indexed: 12/04/2022] Open
Abstract
Microscopy of stained blood films is essential for the diagnosis of malaria, differentiation of parasite species, and estimation of parasite density performed for assessments of antimalarial drug efficacy. The accuracy and comparability of these measures over time and space are vital to discern the emergence or spread of antimalarial drug resistance. Although evidence-based guidelines for malaria microscopy methods exist, the age-old microscopy techniques for parasitological assessments are subject to considerable methodological variations. The purpose of this review was to explore critically how microscopy methods were reported in published malarial studies between 2013 and 2017 with the focus on outlining the methodological differences and improving reporting standards in practice.
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Affiliation(s)
- Debashish Das
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Prabin Dahal
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
| | - Mehul Dhorda
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
| | - Barbara Wanjiru Citarella
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
| | - Kalynn Kennon
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
| | - Kasia Stepniewska
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
| | - Ingrid Felger
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Philippe J Guerin
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Infectious Diseases Data Observatory (IDDO), Oxford, United Kingdom
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Amboko B, Stepniewska K, Macharia PM, Machini B, Bejon P, Snow RW, Zurovac D. Trends in health workers' compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010-2016. Malar J 2020; 19:406. [PMID: 33176783 PMCID: PMC7659071 DOI: 10.1186/s12936-020-03479-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined. METHODS Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk). RESULTS Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time. CONCLUSIONS There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.
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Affiliation(s)
- Beatrice Amboko
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Peter M Macharia
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Hossain MS, Commons RJ, Douglas NM, Thriemer K, Alemayehu BH, Amaratunga C, Anvikar AR, Ashley EA, Asih PBS, Carrara VI, Lon C, D’Alessandro U, Davis TME, Dondorp AM, Edstein MD, Fairhurst RM, Ferreira MU, Hwang J, Janssens B, Karunajeewa H, Kiechel JR, Ladeia-Andrade S, Laman M, Mayxay M, McGready R, Moore BR, Mueller I, Newton PN, Thuy-Nhien NT, Noedl H, Nosten F, Phyo AP, Poespoprodjo JR, Saunders DL, Smithuis F, Spring MD, Stepniewska K, Suon S, Suputtamongkol Y, Syafruddin D, Tran HT, Valecha N, Van Herp M, Van Vugt M, White NJ, Guerin PJ, Simpson JA, Price RN. The risk of Plasmodium vivax parasitaemia after P. falciparum malaria: An individual patient data meta-analysis from the WorldWide Antimalarial Resistance Network. PLoS Med 2020; 17:e1003393. [PMID: 33211712 PMCID: PMC7676739 DOI: 10.1371/journal.pmed.1003393] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/25/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is a high risk of Plasmodium vivax parasitaemia following treatment of falciparum malaria. Our study aimed to quantify this risk and the associated determinants using an individual patient data meta-analysis in order to identify populations in which a policy of universal radical cure, combining artemisinin-based combination therapy (ACT) with a hypnozoitocidal antimalarial drug, would be beneficial. METHODS AND FINDINGS A systematic review of Medline, Embase, Web of Science, and the Cochrane Database of Systematic Reviews identified efficacy studies of uncomplicated falciparum malaria treated with ACT that were undertaken in regions coendemic for P. vivax between 1 January 1960 and 5 January 2018. Data from eligible studies were pooled using standardised methodology. The risk of P. vivax parasitaemia at days 42 and 63 and associated risk factors were investigated by multivariable Cox regression analyses. Study quality was assessed using a tool developed by the Joanna Briggs Institute. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018097400). In total, 42 studies enrolling 15,341 patients were included in the analysis, including 30 randomised controlled trials and 12 cohort studies. Overall, 14,146 (92.2%) patients had P. falciparum monoinfection and 1,195 (7.8%) mixed infection with P. falciparum and P. vivax. The median age was 17.0 years (interquartile range [IQR] = 9.0-29.0 years; range = 0-80 years), with 1,584 (10.3%) patients younger than 5 years. 2,711 (17.7%) patients were treated with artemether-lumefantrine (AL, 13 studies), 651 (4.2%) with artesunate-amodiaquine (AA, 6 studies), 7,340 (47.8%) with artesunate-mefloquine (AM, 25 studies), and 4,639 (30.2%) with dihydroartemisinin-piperaquine (DP, 16 studies). 14,537 patients (94.8%) were enrolled from the Asia-Pacific region, 684 (4.5%) from the Americas, and 120 (0.8%) from Africa. At day 42, the cumulative risk of vivax parasitaemia following treatment of P. falciparum was 31.1% (95% CI 28.9-33.4) after AL, 14.1% (95% CI 10.8-18.3) after AA, 7.4% (95% CI 6.7-8.1) after AM, and 4.5% (95% CI 3.9-5.3) after DP. By day 63, the risks had risen to 39.9% (95% CI 36.6-43.3), 42.4% (95% CI 34.7-51.2), 22.8% (95% CI 21.2-24.4), and 12.8% (95% CI 11.4-14.5), respectively. In multivariable analyses, the highest rate of P. vivax parasitaemia over 42 days of follow-up was in patients residing in areas of short relapse periodicity (adjusted hazard ratio [AHR] = 6.2, 95% CI 2.0-19.5; p = 0.002); patients treated with AL (AHR = 6.2, 95% CI 4.6-8.5; p < 0.001), AA (AHR = 2.3, 95% CI 1.4-3.7; p = 0.001), or AM (AHR = 1.4, 95% CI 1.0-1.9; p = 0.028) compared with DP; and patients who did not clear their initial parasitaemia within 2 days (AHR = 1.8, 95% CI 1.4-2.3; p < 0.001). The analysis was limited by heterogeneity between study populations and lack of data from very low transmission settings. Study quality was high. CONCLUSIONS In this meta-analysis, we found a high risk of P. vivax parasitaemia after treatment of P. falciparum malaria that varied significantly between studies. These P. vivax infections are likely attributable to relapses that could be prevented with radical cure including a hypnozoitocidal agent; however, the benefits of such a novel strategy will vary considerably between geographical areas.
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Affiliation(s)
- Mohammad S. Hossain
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- International Centre for Diarrheal Diseases and Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Robert J. Commons
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Internal Medical Services, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Nicholas M. Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Bereket H. Alemayehu
- ICAP at Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | | | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | | | - Verena I. Carrara
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Chanthap Lon
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | | | - Timothy M. E. Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
| | - Arjen M. Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Michael D. Edstein
- Australian Defence Force Malaria and Infectious Disease Institute, Enoggera, Brisbane, Australia
| | - Rick M. Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Marcelo U. Ferreira
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Jimee Hwang
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | | | - Harin Karunajeewa
- Melbourne Medical School–Western Health, The University of Melbourne, Melbourne, Australia
- Western Health Chronic Disease Alliance, Sunshine Hospital, St Albans, Melbourne, Australia
| | - Jean R. Kiechel
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Simone Ladeia-Andrade
- Laboratory of Parasitic Diseases, Oswaldo Cruz Institute/Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
- Amazonian Malaria Initiative/Amazon Network for the Surveillance of Antimalarial Drug Resistance, Ministry of Health of Brazil, Cruzeiro do Sul, Brazil
| | - Moses Laman
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane, Lao PDR
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Brioni R. Moore
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Australia
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Australia
| | - Ivo Mueller
- Division of Population Health and Immunity, The Walter & Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Parasites and Insect Vectors Department, Institut Pasteur, Paris, France
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Harald Noedl
- MARIB—Malaria Research Initiative Bandarban, Vienna, Austria
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Aung P. Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Jeanne R. Poespoprodjo
- Mimika District Hospital, Timika, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
- Paediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - David L. Saunders
- Division of Medicine, United States Army Research Institute of Infectious Diseases, Ft. Detrick, Maryland, United States of America
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
| | - Michele D. Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Yupin Suputtamongkol
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Department of Parasitology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Hien T. Tran
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
| | - Neena Valecha
- National Institute of Malaria Research, Dwarka, New Delhi, India
| | | | - Michele Van Vugt
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Academic Medical Centre, Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Nicholas J. White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, United Kingdom
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
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Elven J, Dahal P, Ashley EA, Thomas NV, Shrestha P, Stepniewska K, Crump JA, Newton PN, Bell D, Reyburn H, Hopkins H, Guérin PJ. Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Africa, 1980-2015. BMC Med 2020; 18:279. [PMID: 32951596 PMCID: PMC7504660 DOI: 10.1186/s12916-020-01744-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/13/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The availability of reliable point-of-care tests for malaria has heralded a paradigm shift in the management of febrile illnesses away from presumptive antimalarial therapy. In the absence of a definitive diagnosis, health care providers are more likely to prescribe empirical antimicrobials to those who test negative for malaria. To improve management and guide further test development, better understanding is needed of the true causative agents and their geographic variability. METHODS A systematic review of published literature was undertaken to characterise the spectrum of pathogens causing non-malaria febrile illness in Africa (1980-2015). Literature searches were conducted in English and French languages in six databases: MEDLINE, EMBASE, Global Health (CABI), WHO Global Health Library, PASCAL, and Bulletin de la Société Française de Parasitologie (BDSP). Selection criteria included reporting on an infection or infections with a confirmed diagnosis, defined as pathogens detected in or cultured from samples from normally sterile sites, or serological evidence of current or past infection. A number of published articles (rather than incidence or prevalence) reporting a given pathogen were presented. RESULTS A total of 16,523 records from 48 African countries were screened, of which 1065 (6.4%) met selection criteria. Bacterial infections were reported in 564 (53.0%) records, viral infections in 374 (35.1%), parasitic infections in 47 (4.4%), fungal infections in nine (0.8%), and 71 (6.7%) publications reported more than one pathogen group. Age range of the study population was not specified in 233 (21.9%) publications. Staphylococcus aureus (18.2%), non-typhoidal Salmonella (17.3%), and Escherichia coli (15.4%) were the commonly reported bacterial infections whereas Rift Valley fever virus (7.4%), yellow fever virus (7.0%), and Ebola virus (6.7%) were the most commonly reported viral infections. Dengue virus infection, previously not thought to be widespread in Africa, was reported in 54 (5.1%) of articles. CONCLUSIONS This review summarises the published reports of non-malaria pathogens that may cause febrile illness in Africa. As the threat of antimicrobial resistance looms, knowledge of the distribution of infectious agents causing fever should facilitate priority setting in the development of new diagnostic tools and improved antimicrobial stewardship. TRIAL REGISTRATION PROSPERO, CRD42016049281.
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Affiliation(s)
- Jeanne Elven
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
| | - Nigel V Thomas
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Poojan Shrestha
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Paul N Newton
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Mahosot Hospital, Vientiane, Laos
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - David Bell
- Independent consultant, Issaquah, Washington, USA
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Philippe J Guérin
- Infectious Diseases Data Observatory, University of Oxford, New Richards Building,Old Road Campus,Headington, Oxford, OX3 7LG, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Shrestha P, Dahal P, Ogbonnaa-Njoku C, Das D, Stepniewska K, Thomas NV, Hopkins H, Crump JA, Bell D, Newton PN, Ashley EA, Guérin PJ. Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Southern Asia and South-eastern Asia, 1980-2015. BMC Med 2020; 18:299. [PMID: 32951591 PMCID: PMC7504862 DOI: 10.1186/s12916-020-01745-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/13/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the absence of definitive diagnosis, healthcare providers are likely to prescribe empirical antibacterials to those who test negative for malaria. This problem is of critical importance in Southern Asia (SA) and South-eastern Asia (SEA) where high levels of antimicrobial consumption and high prevalence of antimicrobial resistance have been reported. To improve management and guide further diagnostic test development, better understanding is needed of the true causative agents of fever and their geographical variability. METHODS We conducted a systematic review of published literature (1980-2015) to characterise the spectrum of pathogens causing non-malarial febrile illness in SA and SEA. We searched six databases in English and French languages: MEDLINE, EMBASE, Global Health (CABI) database, WHO Global Health Library, PASCAL, and Bulletin de la Société Française de Parasitologie (BDSP). Selection criteria included reporting on an infection or infections with a confirmed diagnosis, defined as pathogens detected in or cultured from samples from normally sterile sites, or serological evidence of current or past infection. RESULTS A total of 29,558 records from 19 countries in SA and SEA were screened, of which 2410 (8.1%) met the selection criteria. Bacterial aetiologies were reported in 1235 (51.2%) articles, viral in 846 (35.1%), parasitic in 132 (5.5%), and fungal in 54 (2.2%), and 143 (6.0%) articles reported more than one pathogen group. In descending order of frequency, Salmonella Typhi, Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and coagulase negative Staphylococcus were the commonly reported bacteria, while dengue virus, chikungunya virus, Japanese encephalitis virus, hepatitis B virus, and hepatitis C virus were common viral pathogens reported. Reports of rarely reported or emerging pathogens included a case report of Borrelia burgdorferi (Lyme disease) in India in 2010 and reports of Nipah virus in Singapore and India. CONCLUSIONS This review summarises the reported non-malaria pathogens that may cause febrile illness in SA and SEA. The findings emphasise the need of standardising the reporting of aetiological studies to develop effective, evidence-based fever management and improved surveillance. Research and development of diagnostic tools would benefit from up-to-date epidemiological reporting of the regional diversities of non-malaria fever aetiologies. TRIAL REGISTRATION PROSPERO registration, CRD42016049281.
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Affiliation(s)
- Poojan Shrestha
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Chinwe Ogbonnaa-Njoku
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Debashish Das
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nigel V. Thomas
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Paul N. Newton
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Philippe J. Guérin
- Infectious Diseases Data Observatory (IDDO), University of Oxford, NDMRB, Old Road Campus, Oxford, OX3 7FZ UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Stepniewska K, Humphreys GS, Gonçalves BP, Craig E, Gosling R, Guerin PJ, Price RN, Barnes KI, Raman J, Smit MR, D’Alessandro U, Stone WJR, Bjorkman A, Samuels AM, Arroyo-Arroyo MI, Bastiaens GJH, Brown JM, Dicko A, El-Sayed BB, Elzaki SEG, Eziefula AC, Kariuki S, Kwambai TK, Maestre AE, Martensson A, Mosha D, Mwaiswelo RO, Ngasala BE, Okebe J, Roh ME, Sawa P, Tiono AB, Chen I, Drakeley CJ, Bousema T. Efficacy of Single-Dose Primaquine With Artemisinin Combination Therapy on Plasmodium falciparum Gametocytes and Transmission: An Individual Patient Meta-Analysis. J Infect Dis 2020; 225:1215-1226. [PMID: 32778875 PMCID: PMC8974839 DOI: 10.1093/infdis/jiaa498] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/06/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Since the World Health Organization recommended single low-dose (0.25 mg/kg) primaquine (PQ) in combination with artemisinin-based combination therapies (ACTs) in areas of low transmission or artemisinin-resistant Plasmodium falciparum, several single-site studies have been conducted to assess efficacy. METHODS An individual patient meta-analysis to assess gametocytocidal and transmission-blocking efficacy of PQ in combination with different ACTs was conducted. Random effects logistic regression was used to quantify PQ effect on (1) gametocyte carriage in the first 2 weeks post treatment; and (2) the probability of infecting at least 1 mosquito or of a mosquito becoming infected. RESULTS In 2574 participants from 14 studies, PQ reduced PCR-determined gametocyte carriage on days 7 and 14, most apparently in patients presenting with gametocytemia on day 0 (odds ratio [OR], 0.22; 95% confidence interval [CI], .17-.28 and OR, 0.12; 95% CI, .08-.16, respectively). Rate of decline in gametocyte carriage was faster when PQ was combined with artemether-lumefantrine (AL) compared to dihydroartemisinin-piperaquine (DP) (P = .010 for day 7). Addition of 0.25 mg/kg PQ was associated with near complete prevention of transmission to mosquitoes. CONCLUSIONS Transmission blocking is achieved with 0.25 mg/kg PQ. Gametocyte persistence and infectivity are lower when PQ is combined with AL compared to DP.
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Affiliation(s)
- Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom,Kasia Stepniewska, PhD, WorldWide Antimalarial Resistance Network (WWARN), Centre for Tropical Medicine and Global Health, Churchill Hospital, CCVTM, University of Oxford, Old Road, Oxford OX3 7LE, UK
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom,Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Bronner P Gonçalves
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elaine Craig
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom
| | - Roly Gosling
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA,Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom
| | - Ric N Price
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Norther Territory, Australia,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Karen I Barnes
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,University of Cape Town/Medical Research Council Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jaishree Raman
- University of Cape Town/Medical Research Council Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa,Centre for Emerging Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa,Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Menno R Smit
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Umberto D’Alessandro
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Will J R Stone
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anders Bjorkman
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Aaron M Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA,Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Maria I Arroyo-Arroyo
- Grupo Salud y Comunidad, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Guido J H Bastiaens
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands,Department of Microbiology and Immunology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Joelle M Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alassane Dicko
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Badria B El-Sayed
- Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Salah-Eldin G Elzaki
- Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Alice C Eziefula
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | | | - Titus K Kwambai
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom,Kenya Medical Research Institute, Kisian, Kenya
| | - Amanda E Maestre
- Grupo Salud y Comunidad, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Andreas Martensson
- Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Dominic Mosha
- Bagamoyo Research and Training Centre, Ifakara Health Institute, Bagamoyo, Tanzania,Africa Academy for Public Health, Dar es Salaam, Tanzania
| | - Richard O Mwaiswelo
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Billy E Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Michelle E Roh
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA,Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Patrick Sawa
- Human Health Division, International Centre for Insect Physiology and Ecology, Mbita Point, Kenya
| | - Alfred B Tiono
- Department of Biomedical Sciences, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Ingrid Chen
- Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Chris J Drakeley
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Teun Bousema
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands,Correspondence: Teun Bousema, PhD, Department of Medical Microbiology, Radboud Institute for Health Science, Radboudumc, PO Box 9101, 6500 HB Nijmegen, The Netherlands ()
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28
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Saito M, Mansoor R, Kennon K, Anvikar AR, Ashley EA, Chandramohan D, Cohee LM, D'Alessandro U, Genton B, Gilder ME, Juma E, Kalilani-Phiri L, Kuepfer I, Laufer MK, Lwin KM, Meshnick SR, Mosha D, Mwapasa V, Mwebaza N, Nambozi M, Ndiaye JLA, Nosten F, Nyunt M, Ogutu B, Parikh S, Paw MK, Phyo AP, Pimanpanarak M, Piola P, Rijken MJ, Sriprawat K, Tagbor HK, Tarning J, Tinto H, Valéa I, Valecha N, White NJ, Wiladphaingern J, Stepniewska K, McGready R, Guérin PJ. Efficacy and tolerability of artemisinin-based and quinine-based treatments for uncomplicated falciparum malaria in pregnancy: a systematic review and individual patient data meta-analysis. Lancet Infect Dis 2020; 20:943-952. [PMID: 32530424 PMCID: PMC7391007 DOI: 10.1016/s1473-3099(20)30064-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/17/2020] [Accepted: 01/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malaria in pregnancy affects both the mother and the fetus. However, evidence supporting treatment guidelines for uncomplicated (including asymptomatic) falciparum malaria in pregnant women is scarce and assessed in varied ways. We did a systematic literature review and individual patient data (IPD) meta-analysis to compare the efficacy and tolerability of different artemisinin-based or quinine-based treatments for malaria in pregnant women. METHODS We did a systematic review of interventional or observational cohort studies assessing the efficacy of artemisinin-based or quinine-based treatments in pregnancy. Seven databases (MEDLINE, Embase, Global Health, Cochrane Library, Scopus, Web of Science, and Literatura Latino Americana em Ciencias da Saude) and two clinical trial registries (International Clinical Trials Registry Platform and ClinicalTrials.gov) were searched. The final search was done on April 26, 2019. Studies that assessed PCR-corrected treatment efficacy in pregnancy with follow-up of 28 days or more were included. Investigators of identified studies were invited to share data from individual patients. The outcomes assessed included PCR-corrected efficacy, PCR-uncorrected efficacy, parasite clearance, fever clearance, gametocyte development, and acute adverse events. One-stage IPD meta-analysis using Cox and logistic regression with random-effects was done to estimate the risk factors associated with PCR-corrected treatment failure, using artemether-lumefantrine as the reference. This study is registered with PROSPERO, CRD42018104013. FINDINGS Of the 30 studies assessed, 19 were included, representing 92% of patients in the literature (4968 of 5360 episodes). Risk of PCR-corrected treatment failure was higher for the quinine monotherapy (n=244, adjusted hazard ratio [aHR] 6·11, 95% CI 2·57-14·54, p<0·0001) but lower for artesunate-amodiaquine (n=840, 0·27, 95% 0·14-0·52, p<0·0001), artesunate-mefloquine (n=1028, 0·56, 95% 0·34-0·94, p=0·03), and dihydroartemisinin-piperaquine (n=872, 0·35, 95% CI 0·18-0·68, p=0·002) than artemether-lumefantrine (n=1278) after adjustment for baseline asexual parasitaemia and parity. The risk of gametocyte carriage on day 7 was higher after quinine-based therapy than artemisinin-based treatment (adjusted odds ratio [OR] 7·38, 95% CI 2·29-23·82). INTERPRETATION Efficacy and tolerability of artemisinin-based combination therapies (ACTs) in pregnant women are better than quinine. The lower efficacy of artemether-lumefantrine compared with other ACTs might require dose optimisation. FUNDING The Bill & Melinda Gates Foundation, ExxonMobil Foundation, and the University of Oxford Clarendon Fund.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Dr Makoto Saito, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford OX3 7LG, UK
| | - Rashid Mansoor
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Anupkumar R Anvikar
- Indian Council of Medical Research, National Institute of Malaria Research, New Delhi, India
| | - Elizabeth A Ashley
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Lauren M Cohee
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Umberto D'Alessandro
- Medical Research Council Unit, The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Blaise Genton
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland,University Center of General Medicine and Public Health, Lausanne, Switzerland
| | - Mary Ellen Gilder
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Linda Kalilani-Phiri
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Irene Kuepfer
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, NC, USA
| | | | - Victor Mwapasa
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Norah Mwebaza
- Infectious Disease Research Collaboration, Makerere University, Kampala, Uganda
| | - Michael Nambozi
- Department of Clinical Sciences, Tropical Diseases Research Centre, Ndola, Zambia
| | | | - François Nosten
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Myaing Nyunt
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Sunil Parikh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Myanmar–Oxford Clinical Research Unit, Yangon, Myanmar
| | - Mupawjay Pimanpanarak
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Patrice Piola
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Marcus J Rijken
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Department of Obstetrics and Gynecology, Division of Woman and Baby, University Medical Center Utrecht, Utrecht, Netherlands
| | - Kanlaya Sriprawat
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Harry K Tagbor
- School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Joel Tarning
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Innocent Valéa
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Neena Valecha
- Indian Council of Medical Research, National Institute of Malaria Research, New Delhi, India
| | - Nicholas J White
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Rose McGready
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK,Infectious Diseases Data Observatory (IDDO), Oxford, UK,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK,Correspondence to: Prof Philippe J Guérin, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford OX3 7LG, UK
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29
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Maguire BJ, McLean AR, Rashan S, Antonio ES, Bagaria J, Bentounsi Z, Brack M, Caldwell F, Carrara VI, Citarella BW, Dahal P, Feteh VF, H.B. Guérin M, Kennon K, Bilton Lahaut K, Makuka GJ, Ngu R, Obiesie S, Richmond C, Singh-Phulgenda S, Strudwick S, Tyrrell CS, Schwinn A, King D, Newton PN, Price RN, Merson L, Stepniewska K, Guérin PJ. Baseline results of a living systematic review for COVID-19 clinical trial registrations. Wellcome Open Res 2020; 5:116. [PMID: 33154979 PMCID: PMC7610178 DOI: 10.12688/wellcomeopenres.15933.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 01/12/2023] Open
Abstract
Background: Since the coronavirus disease 2019 (COVID-19) outbreak was first reported in December 2019, many independent trials have been planned that aim to answer similar questions. Tools allowing researchers to review studies already underway can facilitate collaboration, cooperation and harmonisation. The Infectious Diseases Data Observatory (IDDO) has undertaken a living systematic review (LSR) to provide an open, accessible and frequently updated resource summarising characteristics of COVID-19 study registrations. Methods: Review of all eligible trial records identified by systematic searches as of 3 April 2020 and initial synthesis of clinical study characteristics were conducted. In partnership with Exaptive, an open access, cloud-based knowledge graph has been created using the results. Results: There were 728 study registrations which met eligibility criteria and were still active. Median (25 th, 75 th percentile) sample size was 130 (60, 400) for all studies and 134 (70, 300) for RCTs. Eight lower middle and low income countries were represented among the planned recruitment sites. Overall 109 pharmacological interventions or advanced therapy medicinal products covering 23 drug categories were studied. Majority (57%, 62/109) of them were planned only in one study arm, either alone or in combination with other interventions. There were 49 distinct combinations studied with 90% (44/49) of them administered in only one or two study arms. The data and interactive platform are available at https://iddo.cognitive.city/. Conclusions: Baseline review highlighted that the majority of investigations in the first three months of the outbreak were small studies with unique treatment arms, likely to be unpowered to provide solid evidence. The continued work of this LSR will allow a more dependable overview of interventions tested, predict the likely strength of evidence generated, allow fast and informative filtering of relevant trials for specific user groups and provide the rapid guidance needed by investigators and funders to avoid duplication of efforts.
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Affiliation(s)
- Brittany J. Maguire
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Alistair R.D. McLean
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sumayyah Rashan
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emilia Sitsofe Antonio
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Zineb Bentounsi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Matthew Brack
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Verena Ilona Carrara
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford University Research Unit, Mahidol University, Mae Sot, Tak, Thailand
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Barbara Wanjiru Citarella
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Vitalis Fambombi Feteh
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, UK
- Health and Human Development (2HD) Research Network, Douala, Cameroon
| | | | - Kalynn Kennon
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Roland Ngu
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sopuruchukwu Obiesie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Caitlin Richmond
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Samantha Strudwick
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carina S.B. Tyrrell
- Public Health England, London, UK
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | | | - David King
- Exaptive, Inc., Oklahoma City, Oklahoma, USA
| | - Paul N. Newton
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Ric N. Price
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Laura Merson
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Oxford, UK
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philippe J. Guérin
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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30
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Saito M, Mansoor R, Kennon K, Anvikar AR, Ashley EA, Chandramohan D, Cohee LM, D'Alessandro U, Genton B, Gilder ME, Juma E, Kalilani-Phiri L, Kuepfer I, Laufer MK, Lwin KM, Meshnick SR, Mosha D, Muehlenbachs A, Mwapasa V, Mwebaza N, Nambozi M, Ndiaye JLA, Nosten F, Nyunt M, Ogutu B, Parikh S, Paw MK, Phyo AP, Pimanpanarak M, Piola P, Rijken MJ, Sriprawat K, Tagbor HK, Tarning J, Tinto H, Valéa I, Valecha N, White NJ, Wiladphaingern J, Stepniewska K, McGready R, Guérin PJ. Pregnancy outcomes and risk of placental malaria after artemisinin-based and quinine-based treatment for uncomplicated falciparum malaria in pregnancy: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis. BMC Med 2020; 18:138. [PMID: 32482173 PMCID: PMC7263905 DOI: 10.1186/s12916-020-01592-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/14/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Malaria in pregnancy, including asymptomatic infection, has a detrimental impact on foetal development. Individual patient data (IPD) meta-analysis was conducted to compare the association between antimalarial treatments and adverse pregnancy outcomes, including placental malaria, accompanied with the gestational age at diagnosis of uncomplicated falciparum malaria infection. METHODS A systematic review and one-stage IPD meta-analysis of studies assessing the efficacy of artemisinin-based and quinine-based treatments for patent microscopic uncomplicated falciparum malaria infection (hereinafter uncomplicated falciparum malaria) in pregnancy was conducted. The risks of stillbirth (pregnancy loss at ≥ 28.0 weeks of gestation), moderate to late preterm birth (PTB, live birth between 32.0 and < 37.0 weeks), small for gestational age (SGA, birthweight of < 10th percentile), and placental malaria (defined as deposition of malaria pigment in the placenta with or without parasites) after different treatments of uncomplicated falciparum malaria were assessed by mixed-effects logistic regression, using artemether-lumefantrine, the most used antimalarial, as the reference standard. Registration PROSPERO: CRD42018104013. RESULTS Of the 22 eligible studies (n = 5015), IPD from16 studies were shared, representing 95.0% (n = 4765) of the women enrolled in literature. Malaria treatment in this pooled analysis mostly occurred in the second (68.4%, 3064/4501) or third trimester (31.6%, 1421/4501), with gestational age confirmed by ultrasound in 91.5% (4120/4503). Quinine (n = 184) and five commonly used artemisinin-based combination therapies (ACTs) were included: artemether-lumefantrine (n = 1087), artesunate-amodiaquine (n = 775), artesunate-mefloquine (n = 965), and dihydroartemisinin-piperaquine (n = 837). The overall pooled proportion of stillbirth was 1.1% (84/4361), PTB 10.0% (619/4131), SGA 32.3% (1007/3707), and placental malaria 80.1% (2543/3035), and there were no significant differences of considered outcomes by ACT. Higher parasitaemia before treatment was associated with a higher risk of SGA (adjusted odds ratio [aOR] 1.14 per 10-fold increase, 95% confidence interval [CI] 1.03 to 1.26, p = 0.009) and deposition of malaria pigment in the placenta (aOR 1.67 per 10-fold increase, 95% CI 1.42 to 1.96, p < 0.001). CONCLUSIONS The risks of stillbirth, PTB, SGA, and placental malaria were not different between the commonly used ACTs. The risk of SGA was high among pregnant women infected with falciparum malaria despite treatment with highly effective drugs. Reduction of malaria-associated adverse birth outcomes requires effective prevention in pregnant women.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Rashid Mansoor
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | | | - Lauren M Cohee
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Umberto D'Alessandro
- Medical Research Council Unit, The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Blaise Genton
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- University Center of General Medicine and Public Health, Lausanne, Switzerland
| | - Mary Ellen Gilder
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | | | - Linda Kalilani-Phiri
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Irene Kuepfer
- London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Victor Mwapasa
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Norah Mwebaza
- Infectious Disease Research Collaboration, Makerere University, Kampala, Uganda
| | - Michael Nambozi
- Department of Clinical Sciences, Tropical Diseases Research Centre, Ndola, Zambia
| | | | - François Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Myaing Nyunt
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Sunil Parikh
- Yale School of Public Health, New Haven, CT, USA
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Mupawjay Pimanpanarak
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | | | - Marcus J Rijken
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
- Department of Obstetrics and Gynecology, Division of Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kanlaya Sriprawat
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Harry K Tagbor
- School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Joel Tarning
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Innocent Valéa
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Neena Valecha
- ICMR-National Institute of Malaria Research, New Delhi, India
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.
- Infectious Diseases Data Observatory (IDDO), Oxford, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Bretscher MT, Dahal P, Griffin J, Stepniewska K, Bassat Q, Baudin E, D'Alessandro U, Djimde AA, Dorsey G, Espié E, Fofana B, González R, Juma E, Karema C, Lasry E, Lell B, Lima N, Menéndez C, Mombo-Ngoma G, Moreira C, Nikiema F, Ouédraogo JB, Staedke SG, Tinto H, Valea I, Yeka A, Ghani AC, Guerin PJ, Okell LC. The duration of chemoprophylaxis against malaria after treatment with artesunate-amodiaquine and artemether-lumefantrine and the effects of pfmdr1 86Y and pfcrt 76T: a meta-analysis of individual patient data. BMC Med 2020; 18:47. [PMID: 32098634 PMCID: PMC7043031 DOI: 10.1186/s12916-020-1494-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/09/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The majority of Plasmodium falciparum malaria cases in Africa are treated with the artemisinin combination therapies artemether-lumefantrine (AL) and artesunate-amodiaquine (AS-AQ), with amodiaquine being also widely used as part of seasonal malaria chemoprevention programs combined with sulfadoxine-pyrimethamine. While artemisinin derivatives have a short half-life, lumefantrine and amodiaquine may give rise to differing durations of post-treatment prophylaxis, an important additional benefit to patients in higher transmission areas. METHODS We analyzed individual patient data from 8 clinical trials of AL versus AS-AQ in 12 sites in Africa (n = 4214 individuals). The time to PCR-confirmed reinfection after treatment was used to estimate the duration of post-treatment protection, accounting for variation in transmission intensity between settings using hidden semi-Markov models. Accelerated failure-time models were used to identify potential effects of covariates on the time to reinfection. The estimated duration of chemoprophylaxis was then used in a mathematical model of malaria transmission to determine the potential public health impact of each drug when used for first-line treatment. RESULTS We estimated a mean duration of post-treatment protection of 13.0 days (95% CI 10.7-15.7) for AL and 15.2 days (95% CI 12.8-18.4) for AS-AQ overall. However, the duration varied significantly between trial sites, from 8.7-18.6 days for AL and 10.2-18.7 days for AS-AQ. Significant predictors of time to reinfection in multivariable models were transmission intensity, age, drug, and parasite genotype. Where wild type pfmdr1 and pfcrt parasite genotypes predominated (<=20% 86Y and 76T mutants, respectively), AS-AQ provided ~ 2-fold longer protection than AL. Conversely, at a higher prevalence of 86Y and 76T mutant parasites (> 80%), AL provided up to 1.5-fold longer protection than AS-AQ. Our simulations found that these differences in the duration of protection could alter population-level clinical incidence of malaria by up to 14% in under-5-year-old children when the drugs were used as first-line treatments in areas with high, seasonal transmission. CONCLUSION Choosing a first-line treatment which provides optimal post-treatment prophylaxis given the local prevalence of resistance-associated markers could make a significant contribution to reducing malaria morbidity.
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Affiliation(s)
- Michael T Bretscher
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Prabin Dahal
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jamie Griffin
- School of Mathematical Sciences, Queen Mary University of London, London, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Umberto D'Alessandro
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Abdoulaye A Djimde
- Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Emmanuelle Espié
- Epicentre, Paris, France.,Clinical and Epidemiology Department, GSK Vaccines, R&D Center, Wavre, Belgium
| | - Bakary Fofana
- Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Raquel González
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Elizabeth Juma
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Corine Karema
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Bertrand Lell
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria.,Centre de Recherches Medicales de Lambarene, Lambarene, Gabon
| | - Nines Lima
- Department of Paediatrics, University of Calabar, Calabar, Nigeria
| | - Clara Menéndez
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Medicales de Lambarene, Lambarene, Gabon.,Institute for Tropical Medicine, University of Tubingen, Tubingen, Germany.,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clarissa Moreira
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frederic Nikiema
- Institut de Recherche en Science de la Sante, Bobo-Dioulasso, Burkina Faso
| | - Jean B Ouédraogo
- Institut de Recherche en Science de la Sante, Bobo-Dioulasso, Burkina Faso
| | - Sarah G Staedke
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Halidou Tinto
- Institut de Recherche en Science de la Sante, Nanoro, Burkina Faso
| | - Innocent Valea
- Institut de Recherche en Science de la Sante, Nanoro, Burkina Faso
| | - Adoke Yeka
- Uganda Malaria Surveillance Project, Kampala, Uganda
| | - Azra C Ghani
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lucy C Okell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
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Intharabut B, Kingston HW, Srinamon K, Ashley EA, Imwong M, Dhorda M, Woodrow C, Stepniewska K, Silamut K, Day NPJ, Dondorp AM, White NJ. Artemisinin Resistance and Stage Dependency of Parasite Clearance in Falciparum Malaria. J Infect Dis 2020; 219:1483-1489. [PMID: 30657916 PMCID: PMC6467186 DOI: 10.1093/infdis/jiy673] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 12/22/2018] [Indexed: 11/24/2022] Open
Abstract
Background Artemisinin resistance in falciparum malaria is associated with kelch13 propeller mutations, reduced ring stage parasite killing, and, consequently, slow parasite clearance. We assessed how parasite age affects parasite clearance in artemisinin resistance. Methods Developmental stages of Plasmodium falciparum parasites on blood films performed at hospital admission and their kelch13 genotypes were assessed for 816 patients enrolled in a multinational clinical trial of artemisinin combination therapy. Results Early changes in parasitemia level (ie, 0–6 hours after admission) were determined mainly by modal stage of asexual parasite development, whereas the subsequent log-linear decline was determined mainly by kelch13 propeller mutations. Older circulating parasites on admission were associated with more-rapid parasite clearance, particularly in kelch13 mutant infections. The geometric mean parasite clearance half-life decreased by 11.6% (95% CI 3.4%–19.1%) in kelch13 wild-type infections and by 30% (95% CI 17.8%–40.4%) in kelch13 mutant infections as the mean age of circulating parasites rose from 3 to 21 hours. Conclusion Following the start of antimalarial treatment, ongoing parasite sequestration and schizogony both affect initial changes in parasitemia. The greater dependency of parasite clearance half-life on parasite age in artemisinin resistant infections is consistent with ring stage resistance and consequent parasite clearance by sequestration. The stage of parasite development should be incorporated in individual assessments of artemisinin resistance.
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Affiliation(s)
- Benjamas Intharabut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hugh W Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Ketsanee Srinamon
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mehul Dhorda
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,WorldWide Antimalarial Resistance Network, Asia Regional Centre, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Charles Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Asia Regional Centre, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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33
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Dahal P, Stepniewska K, Guerin PJ, D’Alessandro U, Price RN, Simpson JA. Dealing with indeterminate outcomes in antimalarial drug efficacy trials: a comparison between complete case analysis, multiple imputation and inverse probability weighting. BMC Med Res Methodol 2019; 19:215. [PMID: 31775647 PMCID: PMC6882216 DOI: 10.1186/s12874-019-0856-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antimalarial clinical efficacy studies for uncomplicated Plasmodium falciparum malaria frequently encounter situations in which molecular genotyping is unable to discriminate between parasitic recurrence, either new infection or recrudescence. The current WHO guideline recommends excluding these individuals with indeterminate outcomes in a complete case (CC) analysis. Data from the four artemisinin-based combination (4ABC) trial was used to compare the performance of multiple imputation (MI) and inverse probability weighting (IPW) against the standard CC analysis for dealing with indeterminate recurrences. METHODS 3369 study participants from the multicentre study (4ABC trial) with molecularly defined parasitic recurrence treated with three artemisinin-based combination therapies were used to represent a complete dataset. A set proportion of recurrent infections (10, 30 and 45%) were reclassified as missing using two mechanisms: a completely random selection (mechanism 1); missingness weakly dependent (mechanism 2a) and strongly dependent (mechanism 2b) on treatment and transmission intensity. The performance of MI, IPW and CC approaches in estimating the Kaplan-Meier (K-M) probability of parasitic recrudescence at day 28 was then compared. In addition, the maximum likelihood estimate of the cured proportion was presented for further comparison (analytical solution). Performance measures (bias, relative bias, standard error and coverage) were reported as an average from 1000 simulation runs. RESULTS The CC analyses resulted in absolute underestimation of K-M probability of day 28 recrudescence by up to 1.7% and were associated with reduced precision and poor coverage across all the scenarios studied. Both MI and IPW method performed better (greater consistency and greater efficiency) compared to CC analysis. In the absence of censoring, the analytical solution provided the most consistent and accurate estimate of cured proportion compared to the CC analyses. CONCLUSIONS The widely used CC approach underestimates antimalarial failure; IPW and MI procedures provided efficient and consistent estimates and should be considered when reporting the results of antimalarial clinical trials, especially in areas of high transmission, where the proportion of indeterminate outcomes could be large. The analytical solution estimating the cured proportion could provide an alternative approach, in scenarios with minimal censoring due to loss to follow-up or new infections.
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Affiliation(s)
- Prabin Dahal
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Umberto D’Alessandro
- 0000 0004 0606 294Xgrid.415063.5Medical Research Council Unit, Fajara, The Gambia ,0000 0001 2153 5088grid.11505.30Unit of Malariology, Institute of Tropical Medicine, Antwerp, Belgium
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK ,0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Julie A. Simpson
- 0000 0001 2179 088Xgrid.1008.9Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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34
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Rojek AM, Salam A, Ragotte RJ, Liddiard E, Elhussain A, Carlqvist A, Butler M, Kayem N, Castle L, Odondi L', Stepniewska K, Horby PW. A systematic review and meta-analysis of patient data from the West Africa (2013-16) Ebola virus disease epidemic. Clin Microbiol Infect 2019; 25:1307-1314. [PMID: 31284032 PMCID: PMC7116468 DOI: 10.1016/j.cmi.2019.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Over 28 000 individuals were infected with Ebola virus during the West Africa (2013-2016) epidemic, yet there has been criticism of the lack of robust clinical descriptions of Ebola virus disease (EVD) illness from that outbreak. OBJECTIVES To perform a meta-analysis of published data from the epidemic to describe the clinical presentation, evolution of disease, and predictors of mortality in individuals with EVD. To assess the quality and utility of published data for clinical and public health decision-making. DATA SOURCES Primary articles available in PubMed and published between January 2014 and May 2017. ELIGIBILITY Studies that sequentially enrolled individuals hospitalized for EVD and that reported acute clinical outcomes. METHODS We performed meta-analyses using random-effect models and assessed heterogeneity using the I2 method. We assessed data representativeness by comparing meta-analysis estimates with WHO aggregate data. We examined data utility by examining the availability and compatibility of data sets. RESULTS In all, 3653 articles were screened and 34 articles were included, representing 16 independent cohorts of patients (18 overlapping cohorts) and at least 6168 individuals. The pooled estimate for case fatality rate was 51% (95% CI 46%-56%). However, pooling of estimates for clinical presentation, progression, and predictors of mortality in individuals with EVD were hampered by significant heterogeneity, and inadequate data on clinical progression. Our assessment of data quality found that heterogeneity was largely unexplained, and data availability and compatibility were poor. CONCLUSIONS We have quantified a missed opportunity to generate reliable estimates of the clinical manifestations of EVD during the West Africa epidemic. Clinical data standards and data capture platforms are urgently needed.
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Affiliation(s)
- A M Rojek
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK.
| | - A Salam
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK; United Kingdom Public Health Rapid Support Team, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - R J Ragotte
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - E Liddiard
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - A Elhussain
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - A Carlqvist
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - M Butler
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - N Kayem
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - L Castle
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - L 'o Odondi
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
| | - K Stepniewska
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK; WorldWide Antimalarial Resistance Network, Oxford, UK
| | - P W Horby
- Epidemic Diseases Research Group, University of Oxford, Oxford, UK
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Saito M, Mansoor R, Kennon K, McGready R, Nosten F, Guérin PJ, Stepniewska K. Efficacy of artemisinin-based and quinine-based treatments for uncomplicated falciparum malaria in pregnancy: a protocol for systematic review and individual patient data (IPD) meta-analysis. BMJ Open 2019; 9:e027503. [PMID: 31444179 PMCID: PMC6707703 DOI: 10.1136/bmjopen-2018-027503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 06/26/2019] [Accepted: 07/23/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pregnant women are more vulnerable to malaria leading to adverse impact on both mothers and fetuses. However, knowledge on the efficacy and safety of antimalarials in pregnancy is limited by the paucity of randomised control trials and the lack of standardised protocols in this special subpopulation. Pooling individual patient data (IPD) for meta-analysis could address in part these limitations to summarise accurately the currently available evidence on treatment efficacy and risk factors for treatment failure. METHODS AND ANALYSIS To assess the treatment efficacy of artemisinin-based and quinine-based treatments for uncomplicated falciparum malaria in pregnancy, seven databases (Medline, Embase, Global Health, Cochrane Library, Scopus, Web of Science and Literatura Latino Americana em Ciências da Saúde) and two clinical trial registries (International Clinical Trials Registry Platform and ClinicalTrial.gov) were searched. Both interventional and observational cohort studies following up for at least 28 days will be included. IPD of the identified eligible published or unpublished studies will be sought by inviting principal investigators. Raw IPD will be shared through the web-based secure platform developed by the WorldWide Antimalarial Resistance Network using the established methodology. The primary objective is to compare the risk of PCR-corrected treatment failure among different treatments and to find the risk factors. One-stage IPD meta-analysis by Cox model with shared frailty will be conducted. A risk of bias assessment will be conducted to address the impact of unshared potential data and of the quality of individual studies. Potential limitations include difficulty in acquiring the IPD and heterogeneity of the study designs due to the lack of standard. ETHICS AND DISSEMINATION This IPD meta-analysis consists of secondary analyses of existing anonymous data and meets the criteria for waiver of ethics review by the Oxford Tropical Research Ethics Committee. The results of this IPD meta-analysis will be disseminated through open-access publications at peer-reviewed journals. The study results will lead to a better understanding of malaria treatment in pregnancy, which can be used for clinical decision-making and conducting further studies. PROSPERO REGISTRATION NUMBER CRD42018104013.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rashid Mansoor
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - François Nosten
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Disease and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Commons RJ, Simpson JA, Thriemer K, Chu CS, Douglas NM, Abreha T, Alemu SG, Añez A, Anstey NM, Aseffa A, Assefa A, Awab GR, Baird JK, Barber BE, Borghini-Fuhrer I, D'Alessandro U, Dahal P, Daher A, de Vries PJ, Erhart A, Gomes MSM, Grigg MJ, Hwang J, Kager PA, Ketema T, Khan WA, Lacerda MVG, Leslie T, Ley B, Lidia K, Monteiro WM, Pereira DB, Phan GT, Phyo AP, Rowland M, Saravu K, Sibley CH, Siqueira AM, Stepniewska K, Taylor WRJ, Thwaites G, Tran BQ, Hien TT, Vieira JLF, Wangchuk S, Watson J, William T, Woodrow CJ, Nosten F, Guerin PJ, White NJ, Price RN. The haematological consequences of Plasmodium vivax malaria after chloroquine treatment with and without primaquine: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis. BMC Med 2019; 17:151. [PMID: 31366382 PMCID: PMC6670141 DOI: 10.1186/s12916-019-1386-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 07/09/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Malaria causes a reduction in haemoglobin that is compounded by primaquine, particularly in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. The aim of this study was to determine the relative contributions to red cell loss of malaria and primaquine in patients with uncomplicated Plasmodium vivax. METHODS A systematic review identified P. vivax efficacy studies of chloroquine with or without primaquine published between January 2000 and March 2017. Individual patient data were pooled using standardised methodology, and the haematological response versus time was quantified using a multivariable linear mixed effects model with non-linear terms for time. Mean differences in haemoglobin between treatment groups at day of nadir and day 42 were estimated from this model. RESULTS In total, 3421 patients from 29 studies were included: 1692 (49.5%) with normal G6PD status, 1701 (49.7%) with unknown status and 28 (0.8%) deficient or borderline individuals. Of 1975 patients treated with chloroquine alone, the mean haemoglobin fell from 12.22 g/dL [95% CI 11.93, 12.50] on day 0 to a nadir of 11.64 g/dL [11.36, 11.93] on day 2, before rising to 12.88 g/dL [12.60, 13.17] on day 42. In comparison to chloroquine alone, the mean haemoglobin in 1446 patients treated with chloroquine plus primaquine was - 0.13 g/dL [- 0.27, 0.01] lower at day of nadir (p = 0.072), but 0.49 g/dL [0.28, 0.69] higher by day 42 (p < 0.001). On day 42, patients with recurrent parasitaemia had a mean haemoglobin concentration - 0.72 g/dL [- 0.90, - 0.54] lower than patients without recurrence (p < 0.001). Seven days after starting primaquine, G6PD normal patients had a 0.3% (1/389) risk of clinically significant haemolysis (fall in haemoglobin > 25% to < 7 g/dL) and a 1% (4/389) risk of a fall in haemoglobin > 5 g/dL. CONCLUSIONS Primaquine has the potential to reduce malaria-related anaemia at day 42 and beyond by preventing recurrent parasitaemia. Its widespread implementation will require accurate diagnosis of G6PD deficiency to reduce the risk of drug-induced haemolysis in vulnerable individuals. TRIAL REGISTRATION This trial was registered with PROSPERO: CRD42016053312. The date of the first registration was 23 December 2016.
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Affiliation(s)
- Robert J Commons
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia. .,WorldWide Antimalarial Resistance Network (WWARN), Clinical Module, Darwin, Northern Territory, Australia.
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Cindy S Chu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Nicholas M Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tesfay Abreha
- ICAP, Columbia University Mailman School of Public Health, Addis Ababa, Ethiopia
| | - Sisay G Alemu
- Addis Ababa University, Addis Ababa, Ethiopia.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Arletta Añez
- Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain.,Organización Panamericana de Salud, Oficina de País Bolivia, La Paz, Bolivia
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Ashenafi Assefa
- Malaria and Neglected Tropical Diseases Research Team, Bacterial, Parasitic, Zoonotic Diseases Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ghulam R Awab
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nangarhar Medical Faculty, Nangarhar University, Jalalabad, Afghanistan
| | - J Kevin Baird
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Bridget E Barber
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | | | | | - Prabin Dahal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
| | - André Daher
- Institute of Drug Technology (Farmanguinhos), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil.,Vice-presidency of Research and Reference Laboratories, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil.,Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter J de Vries
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | - Annette Erhart
- Medical Research Council Unit The Gambia at LSTMH, Fajara, The Gambia
| | - Margarete S M Gomes
- Superintendência de Vigilância em Saúde do Estado do Amapá - SVS/AP, Macapá, Amapá, Brazil.,Universidade Federal do Amapá - UNIFAP, Macapá, Amapá, Brazil
| | - Matthew J Grigg
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Jimee Hwang
- U.S. President's Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, USA.,Global Health Group, University of California San Francisco, San Francisco, USA
| | - Piet A Kager
- Centre for Infection and Immunity Amsterdam (CINEMA), Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, the Netherlands
| | - Tsige Ketema
- Department of Biology, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Biology, Jimma University, Jimma, Ethiopia
| | - Wasif A Khan
- International Centre for Diarrheal Diseases and Research, Dhaka, Bangladesh
| | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Fundação Oswaldo Cruz, Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Manaus, Brazil
| | - Toby Leslie
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,HealthNet-TPO, Kabul, Afghanistan
| | - Benedikt Ley
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Kartini Lidia
- The Department of Pharmacology and Therapy, Faculty of Medicine, Nusa Cendana University, Kupang, Indonesia
| | - Wuelton M Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Universidade do Estado do Amazonas, Manaus, Brazil
| | - Dhelio B Pereira
- Centro de Pesquisa em Medicina Tropical de Rondônia (CEPEM), Porto Velho, Rondônia, Brazil.,Universidade Federal de Rondônia (UNIR), Porto Velho, Rondônia, Brazil
| | - Giao T Phan
- Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, the Netherlands.,Tropical Diseases Clinical Research Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Aung P Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Mark Rowland
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Kavitha Saravu
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Madhav Nagar, Manipal, Karnataka, India.,Manipal McGill Center for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Carol H Sibley
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Department of Genome Sciences, University of Washington, Seattle, USA
| | - André M Siqueira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
| | - Walter R J Taylor
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Binh Q Tran
- Tropical Diseases Clinical Research Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tran T Hien
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - José Luiz F Vieira
- Federal University of Pará (Universidade Federal do Pará - UFPA), Belém, Pará, Brazil
| | - Sonam Wangchuk
- Public Health Laboratory, Department of Public Health, Ministry of Health, Thimphu, Bhutan
| | - James Watson
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Gleneagles Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Philippe J Guerin
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia. .,WorldWide Antimalarial Resistance Network (WWARN), Clinical Module, Darwin, Northern Territory, Australia. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK. .,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Mansoor R, Dahal P, Humphreys GS, Guerin P, Ashley EA, Stepniewska K. The effect of dose on the antimalarial efficacy of artesunate-mefloquine against Plasmodium falciparum malaria: a protocol for systematic review and individual patient data (IPD) meta-analysis. BMJ Open 2019; 9:e027738. [PMID: 31253619 PMCID: PMC6609048 DOI: 10.1136/bmjopen-2018-027738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/22/2019] [Accepted: 05/29/2019] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Antimalarial posology based on weight bands leaves patients at the margins vulnerable to receiving either lower or higher weight-adjusted (mg/kg) dosages. This article aims to describe the protocol for systematic review and individual patient meta-analysis (MA) for a study of the distribution of artesunate and mefloquine dosage administered in patients with uncomplicated Plasmodium falciparum malaria treated with an artesunate-mefloquine (AS-MQ) regimen. Relationship between mg/kg dose and therapeutic outcomes will be assessed through a one-stage individual participant data (IPD) MA. METHODS AND ANALYSIS Therapeutic efficacy studies with the AS-MQ regimen will be identified by searching the following databases: PUBMED, EMBASE and Web of Science. The corresponding authors of the relevant studies will be requested to share the IPD for the purpose of this MA to a secured repository. All available studies will be standardised using a common data management protocol and pooled into a single database. The relationship between mg/kg dosage and treatment failures will be assessed using a Cox regression model with study sites considered as a shared frailty term. Safety parameters will be explored where available. ETHICS AND DISSEMINATION This IPD MA met the criteria for waiver of ethical review as defined by the Oxford Tropical Research Ethics Committee as the research consisted of secondary analysis of existing anonymous data. The results of this analysis will be disseminated at conferences, WorldWide Antimalarial Resistance Network website and any peer-reviewed publication arising will be made open source. PROSPERO REGISTRATION NUMBER CRD42018103776.
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Affiliation(s)
- Rashid Mansoor
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Prabin Dahal
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Philippe Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Myanmar-Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Dahal P, Guerin PJ, Price RN, Simpson JA, Stepniewska K. Evaluating antimalarial efficacy in single-armed and comparative drug trials using competing risk survival analysis: a simulation study. BMC Med Res Methodol 2019; 19:107. [PMID: 31101088 PMCID: PMC6525412 DOI: 10.1186/s12874-019-0748-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 05/07/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Antimalarial efficacy studies in patients with uncomplicated Plasmodium falciparum are confounded by a new infection (a competing risk event) since this event can potentially preclude a recrudescent event (primary endpoint of interest). The current WHO guidelines recommend censoring competing risk events when deriving antimalarial efficacy. We investigated the impact of considering a new infection as a competing risk event on the estimation of antimalarial efficacy in single-armed and comparative drug trials using two simulation studies. METHODS The first simulation study explored differences in the estimates of treatment failure for areas of varying transmission intensities using the complement of the Kaplan-Meier (K-M) estimate and the Cumulative Incidence Function (CIF). The second simulation study extended this to a comparative drug efficacy trial for comparing the K-M curves using the log-rank test, and Gray's k-sample test for comparing the equality of CIFs. RESULTS The complement of the K-M approach produced larger estimates of cumulative treatment failure compared to the CIF method; the magnitude of which was correlated with the observed proportion of new infection and recrudescence. When the drug efficacy was 90%, the absolute overestimation in failure was 0.3% in areas of low transmission rising to 3.1% in the high transmission settings. In a scenario which is most likely to be observed in a comparative trial of antimalarials, where a new drug regimen is associated with an increased (or decreased) rate of recrudescences and new infections compared to an existing drug, the log-rank test was found to be more powerful to detect treatment differences compared to the Gray's k-sample test. CONCLUSIONS The CIF approach should be considered for deriving estimates of antimalarial efficacy, in high transmission areas or for failing drugs. For comparative studies of antimalarial treatments, researchers need to select the statistical test that is best suited to whether the rate or cumulative risk of recrudescence is the outcome of interest, and consider the potential differing prophylactic periods of the antimalarials being compared.
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Affiliation(s)
- Prabin Dahal
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Sharifi-Malvajerdi S, Zhu F, Fogarty CB, Fay MP, Fairhurst RM, Flegg JA, Stepniewska K, Small DS. Malaria parasite clearance rate regression: an R software package for a Bayesian hierarchical regression model. Malar J 2019; 18:4. [PMID: 30611278 PMCID: PMC6321728 DOI: 10.1186/s12936-018-2631-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/14/2018] [Indexed: 11/29/2022] Open
Abstract
Background Emerging resistance to anti-malarial drugs has led malaria researchers to investigate what covariates (parasite and host factors) are associated with resistance. In this regard, investigation of how covariates impact malaria parasites clearance is often performed using a two-stage approach in which the WWARN Parasite Clearance Estimator or PCE is used to estimate parasite clearance rates and then the estimated parasite clearance is regressed on the covariates. However, the recently developed Bayesian Clearance Estimator instead leads to more accurate results for hierarchial regression modelling which motivated the authors to implement the method as an R package, called “bhrcr”. Methods Given malaria parasite clearance profiles of a set of patients, the “bhrcr” package performs Bayesian hierarchical regression to estimate malaria parasite clearance rates along with the effect of covariates on them in the presence of “lag” and “tail” phases. In particular, the model performs a linear regression of the log clearance rates on covariates to estimate the effects within a Bayesian hierarchical framework. All posterior inferences are obtained by a “Markov Chain Monte Carlo” based sampling scheme which forms the core of the package. Results The “bhrcr” package can be utilized to study malaria parasite clearance data, and specifically, how covariates affect parasite clearance rates. In addition to estimating the clearance rates and the impact of covariates on them, the “bhrcr” package provides tools to calculate the WWARN PCE estimates of the parasite clearance rates as well. The fitted Bayesian model to the clearance profile of each individual, as well as the WWARN PCE estimates, can also be plotted by this package. Conclusions This paper explains the Bayesian Clearance Estimator for malaria researchers including describing the freely available software, thus making these methods accessible and practical for modelling covariates’ effects on parasite clearance rates.
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Affiliation(s)
| | - Feiyu Zhu
- The Graduate Group in Applied Mathematics and Computational Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin B Fogarty
- MIT Sloan School of Management, Massachusetts Institute of Technology, Boston, MA, USA
| | - Michael P Fay
- National Institute of Allergy and Infectious Diseases, Maryland, MD, USA
| | - Rick M Fairhurst
- National Institute of Allergy and Infectious Diseases, Maryland, MD, USA
| | - Jennifer A Flegg
- School of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia
| | - Kasia Stepniewska
- Worldwide Antimalarial Resistance Network (WWARN) and Centre for Tropical Medicine, Oxord, UK
| | - Dylan S Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
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40
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Akech S, Ayieko P, Irimu G, Stepniewska K, English M. Magnitude and pattern of improvement in processes of care for hospitalised children with diarrhoea and dehydration in Kenyan hospitals participating in a clinical network. Trop Med Int Health 2019; 24:73-80. [PMID: 30365213 PMCID: PMC6378700 DOI: 10.1111/tmi.13176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE WHO recommends optimisation of available interventions to reduce deaths of under-five children with diarrhoea and dehydration (DD). Clinical networks may help improve practice across many hospitals but experience with such networks is scarce. We describe magnitude and patterns of changes in processes of care for children with DD over the first 3 years of a clinical network. METHODS Observational study involving children aged 2-59 months with DD admitted to 13 hospitals participating in the clinical network. Processes of individual patient care including agreement of assessment, diagnosis and treatment according to WHO guidelines were combined using the composite Paediatric Admission Quality of Care (PAQC) score (range 0-6). RESULTS Data from 7657 children were analysed and improvements in PAQC scores were observed. Predicted mean PAQC score for all the hospitals at enrolment was 59.8% (95% CI: 54.7, 64.9) but showed a wide variation (variance 10.7%, 95% CI: 5.8, 19.6). Overall mean PAQC score increased by 13.8% (95% CI: 8.7-18.9, SD between hospitals: ±8.2) in the first 12 months, with an average 0.9% (95% CI: 0.3-1.5, SD ± 1.0) increase per month and plateaued thereafter, and changes were similar in two groups of hospitals joining the network at different times. CONCLUSION Adherence to guidelines for children admitted with DD can be improved through participation in a clinical network but improvement is limited, not uniform for all aspects of care and contexts and occurs early. Future research should address these issues.
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Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
| | - Phillip Ayieko
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
| | - Grace Irimu
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
- Department of Paediatrics and Child HealthUniversity of NairobiNairobiKenya
| | - Kasia Stepniewska
- Centre for Tropical MedicineNuffield Department of Clinical MedicineUniversity of OxfordOxfordUK
- Worldwide Antimalarial Resistance NetworkOxfordUK
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
- Centre for Tropical MedicineNuffield Department of Clinical MedicineUniversity of OxfordOxfordUK
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Das D, Grais RF, Okiro EA, Stepniewska K, Mansoor R, van der Kam S, Terlouw DJ, Tarning J, Barnes KI, Guerin PJ. Complex interactions between malaria and malnutrition: a systematic literature review. BMC Med 2018; 16:186. [PMID: 30371344 PMCID: PMC6205776 DOI: 10.1186/s12916-018-1177-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/20/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Despite substantial improvement in the control of malaria and decreased prevalence of malnutrition over the past two decades, both conditions remain heavy burdens that cause hundreds of thousands of deaths in children in resource-poor countries every year. Better understanding of the complex interactions between malaria and malnutrition is crucial for optimally targeting interventions where both conditions co-exist. This systematic review aimed to assess the evidence of the interplay between malaria and malnutrition. METHODS Database searches were conducted in PubMed, Global Health and Cochrane Libraries and articles published in English, French or Spanish between Jan 1980 and Feb 2018 were accessed and screened. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias across studies was assessed using the GRADE approach. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline were followed. RESULTS Of 2945 articles screened from databases, a total of 33 articles were identified looking at the association between malnutrition and risk of malaria and/or the impact of malnutrition in antimalarial treatment efficacy. Large methodological heterogeneity of studies precluded conducting meaningful aggregated data meta-analysis. Divergent results were reported on the effect of malnutrition on malaria risk. While no consistent association between risk of malaria and acute malnutrition was found, chronic malnutrition was relatively consistently associated with severity of malaria such as high-density parasitemia and anaemia. Furthermore, there is little information on the effect of malnutrition on therapeutic responses to artemisinin combination therapies (ACTs) and their pharmacokinetic properties in malnourished children in published literature. CONCLUSIONS The evidence on the effect of malnutrition on malaria risk remains inconclusive. Further analyses using individual patient data could provide an important opportunity to better understand the variability observed in publications by standardising both malaria and nutritional metrics. Our findings highlight the need to improve our understanding of the pharmacodynamics and pharmacokinetics of ACTs in malnourished children. Further clarification on malaria-malnutrition interactions would also serve as a basis for designing future trials and provide an opportunity to optimise antimalarial treatment for this large, vulnerable and neglected population. TRIAL REGISTRATION PROSPERO CRD42017056934 .
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Affiliation(s)
- D Das
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - E A Okiro
- Kemri Wellcome Trust Research Programme, Kilifi, Kenya
| | - K Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - R Mansoor
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - D J Terlouw
- Liverpool School of Tropical Medicine, Liverpool, UK.,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi
| | - J Tarning
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - K I Barnes
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,WorldWide Antimalarial Resistance Network (WWARN) Pharmacology, University of Cape Town, Cape Town, South Africa
| | - P J Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Commons RJ, Simpson JA, Thriemer K, Humphreys GS, Abreha T, Alemu SG, Añez A, Anstey NM, Awab GR, Baird JK, Barber BE, Borghini-Fuhrer I, Chu CS, D'Alessandro U, Dahal P, Daher A, de Vries PJ, Erhart A, Gomes MSM, Gonzalez-Ceron L, Grigg MJ, Heidari A, Hwang J, Kager PA, Ketema T, Khan WA, Lacerda MVG, Leslie T, Ley B, Lidia K, Monteiro WM, Nosten F, Pereira DB, Phan GT, Phyo AP, Rowland M, Saravu K, Sibley CH, Siqueira AM, Stepniewska K, Sutanto I, Taylor WRJ, Thwaites G, Tran BQ, Tran HT, Valecha N, Vieira JLF, Wangchuk S, William T, Woodrow CJ, Zuluaga-Idarraga L, Guerin PJ, White NJ, Price RN. The effect of chloroquine dose and primaquine on Plasmodium vivax recurrence: a WorldWide Antimalarial Resistance Network systematic review and individual patient pooled meta-analysis. Lancet Infect Dis 2018; 18:1025-1034. [PMID: 30033231 PMCID: PMC6105624 DOI: 10.1016/s1473-3099(18)30348-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Chloroquine remains the mainstay of treatment for Plasmodium vivax malaria despite increasing reports of treatment failure. We did a systematic review and meta-analysis to investigate the effect of chloroquine dose and the addition of primaquine on the risk of recurrent vivax malaria across different settings. METHODS A systematic review done in MEDLINE, Web of Science, Embase, and Cochrane Database of Systematic Reviews identified P vivax clinical trials published between Jan 1, 2000, and March 22, 2017. Principal investigators were invited to share individual patient data, which were pooled using standardised methods. Cox regression analyses with random effects for study site were used to investigate the roles of chloroquine dose and primaquine use on rate of recurrence between day 7 and day 42 (primary outcome). The review protocol is registered in PROSPERO, number CRD42016053310. FINDINGS Of 134 identified chloroquine studies, 37 studies (from 17 countries) and 5240 patients were included. 2990 patients were treated with chloroquine alone, of whom 1041 (34·8%) received a dose below the target 25 mg/kg. The risk of recurrence was 32·4% (95% CI 29·8-35·1) by day 42. After controlling for confounders, a 5 mg/kg higher chloroquine dose reduced the rate of recurrence overall (adjusted hazard ratio [AHR] 0·82, 95% CI 0·69-0·97; p=0·021) and in children younger than 5 years (0·59, 0·41-0·86; p=0·0058). Adding primaquine reduced the risk of recurrence to 4·9% (95% CI 3·1-7·7) by day 42, which is lower than with chloroquine alone (AHR 0·10, 0·05-0·17; p<0·0001). INTERPRETATION Chloroquine is commonly under-dosed in the treatment of vivax malaria. Increasing the recommended dose to 30 mg/kg in children younger than 5 years could reduce substantially the risk of early recurrence when primaquine is not given. Radical cure with primaquine was highly effective in preventing early recurrence and may also improve blood schizontocidal efficacy against chloroquine-resistant P vivax. FUNDING Wellcome Trust, Australian National Health and Medical Research Council, and Bill & Melinda Gates Foundation.
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Affiliation(s)
- Robert J Commons
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia; WorldWide Antimalarial Resistance Network, Clinical module, Darwin, NT, Australia; Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, UK; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Tesfay Abreha
- ICAP, Columbia University Mailman School of Public Health, Addis Ababa, Ethiopia
| | - Sisay G Alemu
- College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Arletta Añez
- Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain; Organización Panamericana de Salud, Oficina de país Bolivia, La Paz, Bolivia
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Ghulam R Awab
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nangarhar Medical Faculty, Nangarhar University, Jalalabad Afghanistan
| | - J Kevin Baird
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Bridget E Barber
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | | | - Cindy S Chu
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Umberto D'Alessandro
- Unit of Malariology, Institute of Tropical Medicine, Antwerp, Belgium; Medical Research Council Unit, Fajara, The Gambia
| | - Prabin Dahal
- WorldWide Antimalarial Resistance Network, Oxford, UK; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - André Daher
- Institute of Drug Technology (Farmanguinhos), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; Vice-Presidency of Research and Reference Laboratories, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter J de Vries
- Department of Internal Medicine, Tergooi Hospital, Hilversum, Netherlands
| | - Annette Erhart
- Unit of Malariology, Institute of Tropical Medicine, Antwerp, Belgium; Medical Research Council Unit, Fajara, The Gambia; Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Margarete S M Gomes
- Superintendência de Vigilância em Saúde do Estado do Amapá -SVS/AP, Macapá, Amapá, Brazil; Federal University of Amapá, Macapá, Amapá, Brazil
| | - Lilia Gonzalez-Ceron
- Regional Centre for Public Health Research, National Institute for Public Health, Tapachula, Chiapas, Mexico
| | - Matthew J Grigg
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Aliehsan Heidari
- Department of Medical Parasitology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Jimee Hwang
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Global Health Group, University of California San Francisco, San Francisco, CA, USA
| | - Piet A Kager
- Centre for Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, Netherlands
| | - Tsige Ketema
- Department of Biology, Addis Ababa University, Addis Ababa, Ethiopia; Department of Biology, Jimma University, Jimma, Ethiopia
| | - Wasif A Khan
- International Centre for Diarrheal Diseases and Research, Dhaka, Bangladesh
| | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil; Fundação Oswaldo Cruz, Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Manaus, Brazil
| | - Toby Leslie
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; HealthNet-TPO, Kabul, Afghanistan
| | - Benedikt Ley
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Kartini Lidia
- Department of Pharmacology and Therapy, Faculty of Medicine, Nusa Cendana University, Kupang, Indonesia
| | - Wuelton M Monteiro
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Francois Nosten
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Dhelio B Pereira
- Centro de Pesquisa em Medicina Tropical de Rondônia, Porto Velho, Rondônia, Brazil; Universidade Federal de Rondônia, Porto Velho, Rondônia, Brazil
| | - Giao T Phan
- Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, Netherlands; Tropical Diseases Clinical Research Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Aung P Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Mark Rowland
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Kavitha Saravu
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India; Manipal McGill Center for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Carol H Sibley
- WorldWide Antimalarial Resistance Network, Oxford, UK; Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - André M Siqueira
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil; Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Walter R J Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Binh Q Tran
- Tropical Diseases Clinical Research Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Hien T Tran
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Sonam Wangchuk
- Public Health Laboratory, Department of Public Health, Ministry of Health, Thimphu, Bhutan
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia; Infectious Diseases Unit, Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Division of Clinical Sciences, St George's, University of London, London, UK
| | | | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, UK; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia; WorldWide Antimalarial Resistance Network, Clinical module, Darwin, NT, Australia; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Akech S, Ayieko P, Gathara D, Agweyu A, Irimu G, Stepniewska K, English M. Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study. Lancet Child Adolesc Health 2018; 2:516-524. [PMID: 29971245 PMCID: PMC6004535 DOI: 10.1016/s2352-4642(18)30130-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Diarrhoea causes many deaths in children younger than 5 years and identification of risk factors for death is considered a global priority. The effectiveness of currently recommended fluid management for dehydration in routine settings has also not been examined. METHODS For this observational, association study, we analysed prospective clinical data on admission, immediate treatment, and discharge of children age 1-59 months with diarrhoea and dehydration, which were routinely collected from 13 Kenyan hospitals. We analysed participants with full datasets using multivariable mixed-effects logistic regression to assess risk factors for in-hospital death and effect of correct rehydration on early mortality (within 2 days). FINDINGS Between Oct 1, 2013, and Dec 1, 2016, 8562 children with diarrhoea and dehydration were admitted to hospital and eligible for inclusion in this analysis. Overall mortality was 9% (759 of 8562 participants) and case fatality was directly correlated with severity. Most children (7184 [84%] of 8562) with diarrhoea and dehydration had at least one additional diagnosis (comorbidity). Age of 12 months or younger (adjusted odds ratio [AOR] 1·71, 95% CI 1·42-2·06), female sex (1·41, 1·19-1·66), diarrhoea duration of more than 14 days (2·10, 1·42-3·12), abnormal respiratory signs (3·62, 2·95-4·44), abnormal circulatory signs (2·29, 1·89-2·77), pallor (2·15, 1·76-2·62), use of intravenous fluid (proxy for severity; 1·68, 1·41-2·00), and abnormal neurological signs (3·07, 2·54-3·70) were independently associated with in-hospital mortality across hospitals. Signs of dehydration alone were not associated with in-hospital deaths (AOR 1·08, 0·87-1·35). Correct fluid prescription significantly reduced the risk of early mortality (within 2 days) in all subgroups: abnormal respiratory signs (AOR 1·23, 0·68-2·24), abnormal circulatory signs (0·95, 0·53-1·73), pallor (1·70, 0·95-3·02), dehydration signs only (1·50, 0·79-2·88), and abnormal neurological signs (0·86, 0·51-1·48). INTERPRETATION Children at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care. FUNDING The Wellcome Trust.
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Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Philip Ayieko
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - David Gathara
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi Kenya
| | - Kasia Stepniewska
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Worldwide Antimalarial Resistance Network, Oxford, UK
| | - Mike English
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Kloprogge F, Workman L, Borrmann S, Tékété M, Lefèvre G, Hamed K, Piola P, Ursing J, Kofoed PE, Mårtensson A, Ngasala B, Björkman A, Ashton M, Friberg Hietala S, Aweeka F, Parikh S, Mwai L, Davis TME, Karunajeewa H, Salman S, Checchi F, Fogg C, Newton PN, Mayxay M, Deloron P, Faucher JF, Nosten F, Ashley EA, McGready R, van Vugt M, Proux S, Price RN, Karbwang J, Ezzet F, Bakshi R, Stepniewska K, White NJ, Guerin PJ, Barnes KI, Tarning J. Artemether-lumefantrine dosing for malaria treatment in young children and pregnant women: A pharmacokinetic-pharmacodynamic meta-analysis. PLoS Med 2018; 15:e1002579. [PMID: 29894518 PMCID: PMC5997317 DOI: 10.1371/journal.pmed.1002579] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/04/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The fixed dose combination of artemether-lumefantrine (AL) is the most widely used treatment for uncomplicated Plasmodium falciparum malaria. Relatively lower cure rates and lumefantrine levels have been reported in young children and in pregnant women during their second and third trimester. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic properties of lumefantrine and the pharmacokinetic properties of its metabolite, desbutyl-lumefantrine, in order to inform optimal dosing regimens in all patient populations. METHODS AND FINDINGS A search in PubMed, Embase, ClinicalTrials.gov, Google Scholar, conference proceedings, and the WorldWide Antimalarial Resistance Network (WWARN) pharmacology database identified 31 relevant clinical studies published between 1 January 1990 and 31 December 2012, with 4,546 patients in whom lumefantrine concentrations were measured. Under the auspices of WWARN, relevant individual concentration-time data, clinical covariates, and outcome data from 4,122 patients were made available and pooled for the meta-analysis. The developed lumefantrine population pharmacokinetic model was used for dose optimisation through in silico simulations. Venous plasma lumefantrine concentrations 7 days after starting standard AL treatment were 24.2% and 13.4% lower in children weighing <15 kg and 15-25 kg, respectively, and 20.2% lower in pregnant women compared with non-pregnant adults. Lumefantrine exposure decreased with increasing pre-treatment parasitaemia, and the dose limitation on absorption of lumefantrine was substantial. Simulations using the lumefantrine pharmacokinetic model suggest that, in young children and pregnant women beyond the first trimester, lengthening the dose regimen (twice daily for 5 days) and, to a lesser extent, intensifying the frequency of dosing (3 times daily for 3 days) would be more efficacious than using higher individual doses in the current standard treatment regimen (twice daily for 3 days). The model was developed using venous plasma data from patients receiving intact tablets with fat, and evaluations of alternative dosing regimens were consequently only representative for venous plasma after administration of intact tablets with fat. The absence of artemether-dihydroartemisinin data limited the prediction of parasite killing rates and recrudescent infections. Thus, the suggested optimised dosing schedule was based on the pharmacokinetic endpoint of lumefantrine plasma exposure at day 7. CONCLUSIONS Our findings suggest that revised AL dosing regimens for young children and pregnant women would improve drug exposure but would require longer or more complex schedules. These dosing regimens should be evaluated in prospective clinical studies to determine whether they would improve cure rates, demonstrate adequate safety, and thereby prolong the useful therapeutic life of this valuable antimalarial treatment.
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Affiliation(s)
- Frank Kloprogge
- WorldWide Antimalarial Resistance Network, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
| | - Lesley Workman
- WorldWide Antimalarial Resistance Network, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Steffen Borrmann
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
- Institute for Tropical Medicine, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Mamadou Tékété
- Institute for Tropical Medicine, Eberhard Karls University of Tübingen, Tübingen, Germany
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | | | - Kamal Hamed
- Novartis Pharmaceuticals, East Hanover, New Jersey, United States of America
| | | | - Johan Ursing
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Danderyds Hospital, Stockholm, Sweden
- Bandim Health Project, Bissau, Guinea-Bissau
| | - Poul Erik Kofoed
- Bandim Health Project, Bissau, Guinea-Bissau
- Department of Paediatrics, Kolding Hospital, Kolding, Denmark
| | - Andreas Mårtensson
- Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Billy Ngasala
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Michael Ashton
- Department of Pharmacology, University of Gothenburg, Gothenburg, Sweden
| | - Sofia Friberg Hietala
- Department of Pharmacology, University of Gothenburg, Gothenburg, Sweden
- Pharmetheus, Uppsala, Sweden
| | - Francesca Aweeka
- UCSF School of Pharmacy, San Francisco, California, United States of America
| | - Sunil Parikh
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Leah Mwai
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
- Institute for Tropical Medicine and Joanna Briggs Institute Affiliate Centre for Evidence Based Health Care Evidence Synthesis and Translation Unit, Afya Research Africa, Nairobi, Kenya
- International Development Research Centre, Ottawa, Ontario, Canada
| | - Timothy M. E. Davis
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Harin Karunajeewa
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Sam Salman
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Francesco Checchi
- Epicentre, Paris, France
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Carole Fogg
- Epicentre, Paris, France
- Faculty of Science, University of Portsmouth, Portsmouth, United Kingdom
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Vientiane, Laos
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Vientiane, Laos
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
| | - Philippe Deloron
- UMR216 Institut de Recherche pour le Développement, Faculté de Pharmacie, Université Paris Descartes, Paris, France
| | | | - François Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Michele van Vugt
- Shoklo Malaria Research Unit, Mae Sot, Thailand
- Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Stephane Proux
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Ric N. Price
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network, Darwin, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Charles Darwin University, Darwin, Northern Territory, Australia
| | - Juntra Karbwang
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Farkad Ezzet
- Novartis Pharmaceuticals, East Hanover, New Jersey, United States of America
| | | | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
| | - Nicholas J. White
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Philippe J. Guerin
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
| | - Karen I. Barnes
- WorldWide Antimalarial Resistance Network, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joel Tarning
- WorldWide Antimalarial Resistance Network, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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45
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Dahal P, Simpson JA, Dorsey G, Guérin PJ, Price RN, Stepniewska K. Statistical methods to derive efficacy estimates of anti-malarials for uncomplicated Plasmodium falciparum malaria: pitfalls and challenges. Malar J 2017; 16:430. [PMID: 29073901 PMCID: PMC5658934 DOI: 10.1186/s12936-017-2074-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/19/2017] [Indexed: 01/12/2023] Open
Abstract
The Kaplan-Meier (K-M) method is currently the preferred approach to derive an efficacy estimate from anti-malarial trial data. In this approach event times are assumed to be continuous and estimates are generated on the assumption that there is only one cause of failure. In reality, failures are captured at pre-scheduled time points and patients can fail treatment due to a variety of causes other than the primary endpoint, commonly termed competing risk events. Ignoring these underlying assumptions can potentially distort the derived efficacy estimates and result in misleading conclusions. This review details the evolution of statistical methods used to derive anti-malarial efficacy for uncomplicated Plasmodium falciparum malaria and assesses the limitations of the current practices. Alternative approaches are explored and their implementation is discussed using example data from a large multi-site study.
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Affiliation(s)
- Prabin Dahal
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ UK
| | - Julie A. Simpson
- 0000 0001 2179 088Xgrid.1008.9Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Grant Dorsey
- 0000 0001 2297 6811grid.266102.1Department of Medicine, University of California, San Francisco, CA USA
| | - Philippe J. Guérin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ UK
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ UK ,0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ UK
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46
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Malla L, Perera-Salazar R, McFadden E, Ogero M, Stepniewska K, English M. Handling missing data in propensity score estimation in comparative effectiveness evaluations: a systematic review. J Comp Eff Res 2017; 7:271-279. [PMID: 28980833 PMCID: PMC6478118 DOI: 10.2217/cer-2017-0071] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim Even though systematic reviews have examined how aspects of propensity score methods are used, none has reviewed how the challenge of missing data is addressed with these methods. This review there-fore describes how missing data are addressed with propensity score methods in observational comparative effectiveness studies. Methods Published articles on observational comparative effectiveness studies were extracted from MEDLINE and EMBASE databases. Results Our search yielded 167 eligible articles. Majority of these studies (114; 68%) conducted complete case analysis with only 53 of them stating this in the methods. Only 16 articles reported use of multiple imputation. Conclusion Few researchers use correct methods for handling missing data or reported missing data methodology which may lead to reporting biased findings.
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Affiliation(s)
- Lucas Malla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily McFadden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Morris Ogero
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Kasia Stepniewska
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,WorldWide Antimalarial Resistance Network, Oxford, UK
| | - Mike English
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
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47
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Fanello C, Onyamboko M, Lee SJ, Woodrow C, Setaphan S, Chotivanich K, Buffet P, Jauréguiberry S, Rockett K, Stepniewska K, Day NPJ, White NJ, Dondorp AM. Post-treatment haemolysis in African children with hyperparasitaemic falciparum malaria; a randomized comparison of artesunate and quinine. BMC Infect Dis 2017; 17:575. [PMID: 28818049 PMCID: PMC5561573 DOI: 10.1186/s12879-017-2678-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/09/2017] [Indexed: 11/10/2022] Open
Abstract
Background Parenteral artesunate is the treatment of choice for severe malaria. Recently, haemolytic anaemia occurring 1 to 3 weeks after artesunate treatment of falciparum malaria has been reported in returning travellers in temperate countries. Methods To assess these potential safety concerns in African children, in whom most deaths from malaria occur, an open-labelled, randomized controlled trial was conducted in Kinshasa, Democratic Republic of Congo. 217 children aged between 6 months and 14 years with acute uncomplicated falciparum malaria and parasite densities over 100,000/μL were randomly allocated to intravenous artesunate or quinine, hospitalized for 3 days and then followed for 42 days. Results The immediate reduction in haemoglobin was less with artesunate than with quinine: median (IQR) fall at 72 h 1.4 g/dL (0.90–1.95) vs. 1.7 g/dL (1.10–2.40) (p = 0.009). This was explained by greater pitting then recirculation of once infected erythrocytes. Only 5% of patients (in both groups) had a ≥ 10% reduction in haemoglobin after day 7 (p = 0.1). One artesunate treated patient with suspected concomitant sepsis had a protracted clinical course and required a blood transfusion on day 14. Conclusions Clinically significant delayed haemolysis following parenteral artesunate is uncommon in African children hospitalised with acute falciparum malaria and high parasitaemias. Trial registration ClinicalTrials.gov; Identifier: NCT02092766 (18/03/2014) Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2678-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Fanello
- 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.
| | - M Onyamboko
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - S J Lee
- 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
| | - C Woodrow
- 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
| | - S Setaphan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - K Chotivanich
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - P Buffet
- Institut National de la Transfusion Sanguine, Université Paris Descartes/INSERM UMR_S 1134, Paris, France.,Laboratoire d'Excellence GR-Ex, Paris, France.,Assistance Publique-Hôpitaux de Paris, Centre National de Référence du Paludisme, Paris, France
| | - S Jauréguiberry
- Assistance Publique-Hôpitaux de Paris, Centre National de Référence du Paludisme, Paris, France
| | - K Rockett
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - K Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,WorldWide Antimalarial Resistance Network, Oxford, UK
| | - N P J Day
- 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
| | - N J White
- 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
| | - A 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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48
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White LJ, Lee SJ, Stepniewska K, Simpson JA, Dwell SLM, Arunjerdja R, Singhasivanon P, White NJ, Nosten F, McGready R. Correction to 'Estimation of gestational age from fundal height: a solution for resource-poor settings'. J R Soc Interface 2016; 12:20150978. [PMID: 26631335 DOI: 10.1098/rsif.2015.0978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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49
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Imwong M, Stepniewska K, Tripura R, Peto TJ, Lwin KM, Vihokhern B, Wongsaen K, von Seidlein L, Dhorda M, Snounou G, Keereecharoen L, Singhasivanon P, Sirithiranont P, Chalk J, Nguon C, Day NPJ, Nosten F, Dondorp A, White NJ. Numerical Distributions of Parasite Densities During Asymptomatic Malaria. J Infect Dis 2015; 213:1322-9. [PMID: 26681777 PMCID: PMC4799672 DOI: 10.1093/infdis/jiv596] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/03/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Asymptomatic parasitemia is common even in areas of low seasonal malaria transmission, but the true proportion of the population infected has not been estimated previously because of the limited sensitivity of available detection methods. METHODS Cross-sectional malaria surveys were conducted in areas of low seasonal transmission along the border between eastern Myanmar and northwestern Thailand and in western Cambodia. DNA was quantitated by an ultrasensitive polymerase chain reaction (uPCR) assay (limit of accurate detection, 22 parasites/mL) to characterize parasite density distributions for Plasmodium falciparum and Plasmodium vivax, and the proportions of undetected infections were imputed. RESULTS The prevalence of asymptomatic malaria as determined by uPCR was 27.5% (1303 of 4740 people tested). Both P. vivax and P. falciparum density distributions were unimodal and log normal, with modal values well within the quantifiable range. The estimated proportions of all parasitemic individuals identified by uPCR were >70% among individuals infected with P. falciparum and >85% among those infected with P. vivax. Overall, 83% of infections were predicted to be P. vivax infections, 13% were predicted to be P. falciparum infections, and 4% were predicted to be mixed infections. Geometric mean parasite densities were similar; 5601 P. vivax parasites/mL and 5158 P. falciparum parasites/mL. CONCLUSIONS This uPCR method identified most infected individuals in malaria-endemic areas. Malaria parasitemia persists in humans at levels that optimize the probability of generating transmissible gametocyte densities without causing illness.
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Affiliation(s)
- Mallika Imwong
- Mahidol Oxford Research Unit Department of Molecular Tropical Medicine and Genetics
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford WWARN, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Tak, Thailand
| | - Benchawan Vihokhern
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Tak, Thailand
| | - Klanarong Wongsaen
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Tak, Thailand
| | - Lorenz von Seidlein
- Mahidol Oxford Research Unit Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Mehul Dhorda
- WorldWide Antimalarial Resistance Network (WWARN)
| | - Georges Snounou
- Sorbonne Universités, UPMC Univ Paris 06, UPMC UMRS CR7 Centre d'Immunologie et de Maladies Infectieuses-Paris, Institut National de la Santé et de la Recherche Medicale U1135-Centre National de la Recherche Scientifique ERL 8255, Paris, France
| | - Lilly Keereecharoen
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Tak, Thailand
| | - Pratap Singhasivanon
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok
| | | | | | - Chea Nguon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Nicholas P J Day
- Mahidol Oxford Research Unit Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Francois Nosten
- Mahidol Oxford Research Unit Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Tak, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Arjen Dondorp
- Mahidol Oxford Research Unit Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Nicholas J White
- Mahidol Oxford Research Unit Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
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50
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Abdulla S, Ashley EA, Bassat Q, Bethell D, Björkman A, Borrmann S, D'Alessandro U, Dahal P, Day NP, Diakite M, Djimde AA, Dondorp AM, Duong S, Edstein MD, Fairhurst RM, Faiz MA, Falade C, Flegg JA, Fogg C, Gonzalez R, Greenwood B, Guérin PJ, Guthmann JP, Hamed K, Hien TT, Htut Y, Juma E, Lim P, Mårtensson A, Mayxay M, Mokuolu OA, Moreira C, Newton P, Noedl H, Nosten F, Ogutu BR, Onyamboko MA, Owusu-Agyei S, Phyo AP, Premji Z, Price RN, Pukrittayakamee S, Ramharter M, Sagara I, Se Y, Suon S, Stepniewska K, Ward SA, White NJ, Winstanley PA. Baseline data of parasite clearance in patients with falciparum malaria treated with an artemisinin derivative: an individual patient data meta-analysis. Malar J 2015; 14:359. [PMID: 26390866 PMCID: PMC4578675 DOI: 10.1186/s12936-015-0874-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/26/2015] [Indexed: 11/15/2022] Open
Abstract
Background Artemisinin resistance in Plasmodium falciparum manifests as slow parasite clearance but this measure is also influenced by host immunity, initial parasite biomass and partner drug efficacy. This study collated data from clinical trials of artemisinin derivatives in falciparum malaria with frequent
parasite counts to provide reference parasite clearance estimates stratified by location, treatment and time, to examine host factors affecting parasite clearance, and to assess the relationships between parasite clearance and risk of recrudescence during follow-up. Methods Data from 24 studies, conducted from 1996 to 2013, with frequent parasite counts were pooled. Parasite clearance half-life (PC1/2) was estimated using the WWARN Parasite Clearance Estimator. Random effects regression models accounting for study and site heterogeneity were used to explore factors affecting PC1/2 and risk of recrudescence within areas with reported delayed parasite clearance (western Cambodia, western Thailand after 2000, southern Vietnam, southern Myanmar) and in all other areas where parasite populations are artemisinin sensitive. Results PC1/2 was estimated in 6975 patients, 3288 of whom also had treatment outcomes evaluate d during 28–63 days follow-up, with 93 (2.8 %) PCR-confirmed recrudescences. In areas with artemisinin-sensitive parasites, the median PC1/2 following three-day artesunate treatment (4 mg/kg/day) ranged from 1.8 to 3.0 h and the proportion of patients with PC1/2 >5 h from 0 to 10 %. Artesunate doses of 4 mg/kg/day decreased PC1/2 by 8.1 % (95 % CI 3.2–12.6) compared to 2 mg/kg/day, except in populations with delayed parasite clearance. PC1/2 was longer in children and in patients with fever or anaemia at enrolment. Long PC1/2 (HR = 2.91, 95 % CI 1.95–4.34 for twofold increase, p < 0.001) and high initial parasitaemia (HR = 2.23, 95 % CI 1.44–3.45 for tenfold increase, p < 0.001) were associated independently with an increased risk of recrudescence. In western Cambodia, the region with the highest prevalence of artemisinin resistance, there was no evidence for increasing PC1/2 since 2007. Conclusions Several factors affect PC1/2. As substantial heterogeneity in parasite clearance exists between locations, early detection of artemisinin resistance requires reference PC1/2 data. Studies with frequent parasite count measurements to characterize PC1/2 should be encouraged. In western Cambodia, where PC1/2 values are longest, there is no evidence for recent emergence of higher levels of artemisinin resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0874-1) contains supplementary material, which is available to authorized users.
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