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Verrest L, Monnerat S, Musa AM, Mbui J, Khalil EAG, Olobo J, Wasunna M, Chu WY, Huitema ADR, Schallig HDFH, Alves F, Dorlo TPC. Leishmania blood parasite dynamics during and after treatment of visceral leishmaniasis in Eastern Africa: A pharmacokinetic-pharmacodynamic model. PLoS Negl Trop Dis 2024; 18:e0012078. [PMID: 38640118 PMCID: PMC11062534 DOI: 10.1371/journal.pntd.0012078] [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: 05/09/2023] [Revised: 05/01/2024] [Accepted: 03/18/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND With the current treatment options for visceral leishmaniasis (VL), recrudescence of the parasite is seen in a proportion of patients. Understanding parasite dynamics is crucial to improving treatment efficacy and predicting patient relapse in cases of VL. This study aimed to characterize the kinetics of circulating Leishmania parasites in the blood, during and after different antileishmanial therapies, and to find predictors for clinical relapse of disease. METHODS Data from three clinical trials, in which Eastern African VL patients received various antileishmanial regimens, were combined in this study. Leishmania kinetoplast DNA was quantified in whole blood with real-time quantitative PCR (qPCR) before, during, and up to six months after treatment. An integrated population pharmacokinetic-pharmacodynamic model was developed using non-linear mixed effects modelling. RESULTS Parasite proliferation was best described by an exponential growth model, with an in vivo parasite doubling time of 7.8 days (RSE 12%). Parasite killing by fexinidazole, liposomal amphotericin B, sodium stibogluconate, and miltefosine was best described by linear models directly relating drug concentrations to the parasite elimination rate. After treatment, parasite growth was assumed to be suppressed by the host immune system, described by an Emax model driven by the time after treatment. No predictors for the high variability in onset and magnitude of the immune response could be identified. Model-based individual predictions of blood parasite load on Day 28 and Day 56 after start of treatment were predictive for clinical relapse of disease. CONCLUSION This semi-mechanistic pharmacokinetic-pharmacodynamic model adequately captured the blood parasite dynamics during and after treatment, and revealed that high blood parasite loads on Day 28 and Day 56 after start of treatment are an early indication for VL relapse, which could be a useful biomarker to assess treatment efficacy of a treatment regimen in a clinical trial setting.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Ahmed M. Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Joseph Olobo
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi), Nairobi, Kenya
| | - Wan-Yu Chu
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D. R. Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Henk D. F. H. Schallig
- Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Center, Amsterdam, the Netherlands
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Thomas P. C. Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Verrest L, Roseboom IC, Wasunna M, Mbui J, Njenga S, Musa AM, Olobo J, Mohammed R, Ritmeijer K, Chu WY, Huitema ADR, Solomos A, Alves F, Dorlo TPC. Population pharmacokinetics of a combination of miltefosine and paromomycin in Eastern African children and adults with visceral leishmaniasis. J Antimicrob Chemother 2023; 78:2702-2714. [PMID: 37726401 PMCID: PMC10631828 DOI: 10.1093/jac/dkad286] [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: 05/12/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES To improve visceral leishmaniasis (VL) treatment in Eastern Africa, 14- and 28-day combination regimens of paromomycin plus allometrically dosed miltefosine were evaluated. As the majority of patients affected by VL are children, adequate paediatric exposure to miltefosine and paromomycin is key to ensuring good treatment response. METHODS Pharmacokinetic data were collected in a multicentre randomized controlled trial in VL patients from Kenya, Sudan, Ethiopia and Uganda. Patients received paromomycin (20 mg/kg/day for 14 days) plus miltefosine (allometric dose for 14 or 28 days). Population pharmacokinetic models were developed. Adequacy of exposure and target attainment of paromomycin and miltefosine were evaluated in children and adults. RESULTS Data from 265 patients (59% ≤12 years) were available for this pharmacokinetic analysis. Paromomycin exposure was lower in paediatric patients compared with adults [median (IQR) end-of-treatment AUC0-24h 187 (162-203) and 242 (217-328) µg·h/mL, respectively], but were both within the IQR of end-of-treatment exposure in Kenyan and Sudanese adult patients from a previous study. Cumulative miltefosine end-of-treatment exposure in paediatric patients and adults [AUCD0-28 517 (464-552) and 524 (456-567) µg·day/mL, respectively] and target attainment [time above the in vitro susceptibility value EC90 27 (25-28) and 30 (28-32) days, respectively] were comparable to previously observed values in adults. CONCLUSIONS Paromomycin and miltefosine exposure in this new combination regimen corresponded to the desirable levels of exposure, supporting the implementation of the shortened 14 day combination regimen. Moreover, the lack of a clear exposure-response and exposure-toxicity relationship indicated adequate exposure within the therapeutic range in the studied population, including paediatric patients.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ignace C Roseboom
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | - Wan-Yu Chu
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Younis BM, Mudawi Musa A, Monnerat S, Abdelrahim Saeed M, Awad Gasim Khalil E, Elbashir Ahmed A, Ahmed Ali M, Noureldin A, Muthoni Ouattara G, Nyakaya GM, Teshome S, Omollo T, Ochieng M, Egondi T, Mmbone M, Chu WY, Dorlo TPC, Zijlstra EE, Wasunna M, Alvar J, Alves F. Safety and efficacy of paromomycin/miltefosine/liposomal amphotericin B combinations for the treatment of post-kala-azar dermal leishmaniasis in Sudan: A phase II, open label, randomized, parallel arm study. PLoS Negl Trop Dis 2023; 17:e0011780. [PMID: 37988402 PMCID: PMC10721181 DOI: 10.1371/journal.pntd.0011780] [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: 04/26/2023] [Revised: 12/14/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Treatment for post-kala-azar dermal leishmaniasis (PKDL) in Sudan is currently recommended only for patients with persistent or severe disease, mainly because of the limitations of current therapies, namely toxicity and long hospitalization. We assessed the safety and efficacy of miltefosine combined with paromomycin and liposomal amphotericin B (LAmB) for the treatment of PKDL in Sudan. METHODOLOGY/PRINCIPAL FINDINGS An open-label, phase II, randomized, parallel-arm, non-comparative trial was conducted in patients with persistent (stable or progressive disease for ≥ 6 months) or grade 3 PKDL, aged 6 to ≤ 60 years in Sudan. The median age was 9.0 years (IQR 7.0-10.0y) and 87% of patients were ≤12 years old. Patients were randomly assigned to either daily intra-muscular paromomycin (20mg/kg, 14 days) plus oral miltefosine (allometric dose, 42 days)-PM/MF-or LAmB (total dose of 20mg/kg, administered in four injections in week one) and oral miltefosine (allometric dose, 28 days)-LAmB/MF. The primary endpoint was a definitive cure at 12 months after treatment onset, defined as clinical cure (100% lesion resolution) and no additional PKDL treatment between end of therapy and 12-month follow-up assessment. 104/110 patients completed the trial. Definitive cure at 12 months was achieved in 54/55 (98.2%, 95% CI 90.3-100) and 44/55 (80.0%, 95% CI 70.2-91.9) of patients in the PM/MF and AmB/MF arms, respectively, in the mITT set (all randomized patients receiving at least one dose of treatment; in case of error of treatment allocation, the actual treatment received was used in the analysis). No SAEs or deaths were reported, and most AEs were mild or moderate. At least one adverse drug reaction (ADR) was reported in 13/55 (23.6%) patients in PM/MF arm and 28/55 (50.9%) in LAmB/MF arm, the most frequent being miltefosine-related vomiting and nausea, and LAmB-related hypokalaemia; no ocular or auditory ADRs were reported. CONCLUSIONS/SIGNIFICANCE The PM/MF regimen requires shorter hospitalization than the currently recommended 60-90-day treatment, and is safe and highly efficacious, even for patients with moderate and severe PKDL. It can be administered at primary health care facilities, with LAmB/MF as a good alternative. For future VL elimination, we need new, safe oral therapies for all patients with PKDL. TRIAL REGISTRATION ClinicalTrials.gov NCT03399955, https://clinicaltrials.gov/study/NCT03399955 ClinicalTrials.gov ClinicalTrials.gov.
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Affiliation(s)
- Brima Musa Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Ahmed Mudawi Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | | | | | - Mujahid Ahmed Ali
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Ali Noureldin
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | | | | | | | | | | | - Wan-Yu Chu
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | | | - Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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Musa AM, Mbui J, Mohammed R, Olobo J, Ritmeijer K, Alcoba G, Muthoni Ouattara G, Egondi T, Nakanwagi P, Omollo T, Wasunna M, Verrest L, Dorlo TPC, Musa Younis B, Nour A, Taha Ahmed Elmukashfi E, Ismail Omer Haroun A, Khalil EAG, Njenga S, Fikre H, Mekonnen T, Mersha D, Sisay K, Sagaki P, Alvar J, Solomos A, Alves F. Paromomycin and Miltefosine Combination as an Alternative to Treat Patients With Visceral Leishmaniasis in Eastern Africa: A Randomized, Controlled, Multicountry Trial. Clin Infect Dis 2022; 76:e1177-e1185. [PMID: 36164254 PMCID: PMC9907539 DOI: 10.1093/cid/ciac643] [Citation(s) in RCA: 4] [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: 05/04/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study aimed to determine whether paromomycin plus miltefosine (PM/MF) is noninferior to sodium stibogluconate plus paromomycin (SSG/PM) for treatment of primary visceral leishmaniasis in eastern Africa. METHODS An open-label, phase 3, randomized, controlled trial was conducted in adult and pediatric patients at 7 sites in eastern Africa. Patients were randomly assigned to either 20 mg/kg paromomycin plus allometric dose of miltefosine (14 days), or 20 mg/kg sodium stibogluconate plus 15 mg/kg paromomycin (17 days). The primary endpoint was definitive cure after 6 months. RESULTS Of 439 randomized patients, 424 completed the trial. Definitive cure at 6 months was 91.2% (155 of 170) and 91.8% (156 of 170) in the PM/MF and SSG/PM arms in primary efficacy modified intention-to-treat analysis (difference, 0.6%; 97.5% confidence interval [CI], -6.2 to 7.4), narrowly missing the noninferiority margin of 7%. In the per-protocol analysis, efficacy was 92% (149 of 162) and 91.7% (155 of 169) in the PM/MF and SSG/PM arms (difference, -0.3%; 97.5% CI, -7.0 to 6.5), demonstrating noninferiority. Treatments were well tolerated. Four of 18 serious adverse events were study drug-related, and 1 death was SSG-related. Allometric dosing ensured similar MF exposure in children (<12 years) and adults. CONCLUSIONS PM/MF and SSG/PM efficacies were similar, and adverse drug reactions were as expected given the drugs safety profiles. With 1 less injection each day, reduced treatment duration, and no risk of SSG-associated life-threatening cardiotoxicity, PM/MF is a more patient-friendly alternative for children and adults with primary visceral leishmaniasis in eastern Africa. CLINICAL TRIALS REGISTRATION NCT03129646.
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Affiliation(s)
- Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Leishmaniasis Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | | | | | | | | | - Luka Verrest
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Brima Musa Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Ali Nour
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | | | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Helina Fikre
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Tigist Mekonnen
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | | | | | - Jorge Alvar
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | | | - Fabiana Alves
- Correspondence: F. Alves, DNDi, 15 chemin Camille Vidart, 1202, Geneva, Switzerland ()
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Verrest L, Kip AE, Musa AM, Schoone GJ, Schallig HDFH, Mbui J, Khalil EAG, Younis BM, Olobo J, Were L, Kimutai R, Monnerat S, Cruz I, Wasunna M, Alves F, Dorlo TPC. Blood Parasite Load as an Early Marker to Predict Treatment Response in Visceral Leishmaniasis in Eastern Africa. Clin Infect Dis 2021; 73:775-782. [PMID: 33580234 PMCID: PMC8423463 DOI: 10.1093/cid/ciab124] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/09/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND To expedite the development of new oral treatment regimens for visceral leishmaniasis (VL), there is a need for early markers to evaluate treatment response and predict long-term outcomes. METHODS Data from 3 clinical trials were combined in this study, in which Eastern African VL patients received various antileishmanial therapies. Leishmania kinetoplast DNA was quantified in whole blood with real-time quantitative polymerase chain reaction (qPCR) before, during, and up to 6 months after treatment. The predictive performance of pharmacodynamic parameters for clinical relapse was evaluated using receiver-operating characteristic curves. Clinical trial simulations were performed to determine the power associated with the use of blood parasite load as a surrogate endpoint to predict clinical outcome at 6 months. RESULTS The absolute parasite density on day 56 after start of treatment was found to be a highly sensitive predictor of relapse within 6 months of follow-up at a cutoff of 20 parasites/mL (area under the curve 0.92, specificity 0.91, sensitivity 0.89). Blood parasite loads correlated well with tissue parasite loads (ρ = 0.80) and with microscopy gradings of bone marrow and spleen aspirate smears. Clinical trial simulations indicated a > 80% power to detect a difference in cure rate between treatment regimens if this difference was high (> 50%) and when minimally 30 patients were included per regimen. CONCLUSIONS Blood Leishmania parasite load determined by qPCR is a promising early biomarker to predict relapse in VL patients. Once optimized, it might be useful in dose finding studies of new chemical entities.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anke E Kip
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Sudan
| | - Gerard J Schoone
- Academic Medical Centre, Department of Medical Microbiology, Parasitology Unit, Amsterdam, The Netherlands
| | - Henk D F H Schallig
- Academic Medical Centre, Department of Medical Microbiology, Parasitology Unit, Amsterdam, The Netherlands
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Brima M Younis
- Institute of Endemic Diseases, University of Khartoum, Sudan
| | - Joseph Olobo
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lilian Were
- Drugs for Neglected Diseases initiative (DNDi) Africa, Nairobi, Kenya
| | - Robert Kimutai
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Drugs for Neglected Diseases initiative (DNDi) Africa, Nairobi, Kenya
| | | | - Isra Cruz
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
- National School of Public Health, Instituto de Salud Carlos III, Madrid, Spain
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi) Africa, Nairobi, Kenya
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, The Netherlands
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Kip AE, Blesson S, Alves F, Wasunna M, Kimutai R, Menza P, Mengesha B, Beijnen JH, Hailu A, Diro E, Dorlo TPC. Low antileishmanial drug exposure in HIV-positive visceral leishmaniasis patients on antiretrovirals: an Ethiopian cohort study. J Antimicrob Chemother 2021; 76:1258-1268. [PMID: 33677546 PMCID: PMC8050768 DOI: 10.1093/jac/dkab013] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/05/2021] [Indexed: 01/02/2023] Open
Abstract
Background Despite high HIV co-infection prevalence in Ethiopian visceral leishmaniasis (VL) patients, the adequacy of antileishmanial drug exposure in this population and effect of HIV-VL co-morbidity on pharmacokinetics of antileishmanial and antiretroviral (ARV) drugs is still unknown. Methods HIV-VL co-infected patients received the recommended liposomal amphotericin B (LAmB) monotherapy (total dose 40 mg/kg over 24 days) or combination therapy of LAmB (total dose 30 mg/kg over 11 days) plus 28 days 100 mg/day miltefosine, with possibility to extend treatment for another cycle. Miltefosine, total amphotericin B and ARV concentrations were determined in dried blood spots or plasma using LC–MS/MS. Results Median (IQR) amphotericin B Cmax on Day 1 was 24.6 μg/mL (17.0–34.9 μg/mL), which increased to 40.9 (25.4–53.1) and 33.2 (29.0–46.6) μg/mL on the last day of combination and monotherapy, respectively. Day 28 miltefosine concentration was 18.7 (15.4–22.5) μg/mL. Miltefosine exposure correlated with amphotericin B accumulation. ARV concentrations were generally stable during antileishmanial treatment, although efavirenz Cmin was below the 1 μg/mL therapeutic target for many patients. Conclusions This study demonstrates that antileishmanial drug exposure was low in this cohort of HIV co-infected VL patients. Amphotericin B Cmax was 2-fold lower than previously observed in non-VL patients. Miltefosine exposure in HIV-VL co-infected patients was 35% lower compared with adult VL patients in Eastern Africa, only partially explained by a 19% lower dose, possibly warranting a dose adjustment. Adequate drug exposure in these HIV-VL co-infected patients is especially important given the high proportion of relapses.
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Affiliation(s)
- Anke E Kip
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | | | | | - Peninah Menza
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | - Bewketu Mengesha
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, The Netherlands.,Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Asrat Hailu
- Department of Microbiology, Immunology, and Parasitology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ermias Diro
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, The Netherlands
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Palić S, Kip AE, Beijnen JH, Mbui J, Musa A, Solomos A, Wasunna M, Olobo J, Alves F, Dorlo TPC. Characterizing the non-linear pharmacokinetics of miltefosine in paediatric visceral leishmaniasis patients from Eastern Africa. J Antimicrob Chemother 2021; 75:3260-3268. [PMID: 32780098 PMCID: PMC7566410 DOI: 10.1093/jac/dkaa314] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 06/07/2020] [Indexed: 12/23/2022] Open
Abstract
Background Conventional miltefosine dosing (2.5 mg/kg/day) for treatment of visceral leishmaniasis (VL) is less effective in children than in adults. A higher allometric dose (median 3.2 mg/kg/day) was therefore investigated in paediatric VL patients in Eastern Africa. Results of this trial showed an unforeseen, lower than dose-proportional increase in exposure. Therefore, we performed a pooled model-based analysis of the paediatric data available from both dosing regimens to characterize observed non-linearities in miltefosine pharmacokinetics (PK). Methods Fifty-one children with VL were included in this analysis, treated with either a conventional (n = 21) or allometric (n = 30) miltefosine dosing regimen. PK data were analysed using non-linear mixed-effects modelling. Results A two-compartment model following first-order absorption and linear elimination, with two separate effects on relative oral bioavailability, was found to fit these data best. A 69% lower bioavailability at treatment start was estimated, presumably due to initial malnourishment and malabsorption. Stagnation in miltefosine accumulation in plasma, hampering increased drug exposure, was related to the increase in cumulative dose (mg/kg/day). However, the allometric regimen increased exposure 1.7-fold in the first treatment week and reduced the time to reach the PK target by 17.4%. Conclusions Miltefosine PK in children suffering from VL are characterized by dose-dependent non-linearities that obstruct the initially expected exposure levels. Bioavailability appeared to be affected by the cumulative dose, possibly as a consequence of impaired absorption. Despite this, allometric dosing led to a faster target achievement and increased exposure compared with conventional dosing.
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Affiliation(s)
- Semra Palić
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Anke E Kip
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | - Joseph Olobo
- Department of Immunology and Molecular Biology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Verrest L, Wasunna M, Kokwaro G, Aman R, Musa AM, Khalil EAG, Mudawi M, Younis BM, Hailu A, Hurissa Z, Hailu W, Tesfaye S, Makonnen E, Mekonnen Y, Huitema ADR, Beijnen JH, Kshirsagar SA, Chakravarty J, Rai M, Sundar S, Alves F, Dorlo TPC. Geographical Variability in Paromomycin Pharmacokinetics Does Not Explain Efficacy Differences between Eastern African and Indian Visceral Leishmaniasis Patients. Clin Pharmacokinet 2021; 60:1463-1473. [PMID: 34105063 PMCID: PMC8585822 DOI: 10.1007/s40262-021-01036-8] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/09/2022]
Abstract
Introduction Intramuscular paromomycin monotherapy to treat visceral leishmaniasis (VL) has been shown to be effective for Indian patients, while a similar regimen resulted in lower efficacy in Eastern Africa, which could be related to differences in paromomycin pharmacokinetics. Methods Pharmacokinetic data were available from two randomized controlled trials in VL patients from Eastern Africa and India. African patients received intramuscular paromomycin monotherapy (20 mg/kg for 21 days) or combination therapy (15 mg/kg for 17 days) with sodium stibogluconate. Indian patients received paromomycin monotherapy (15 mg/kg for 21 days). A population pharmacokinetic model was developed for paromomycin in Eastern African and Indian VL patients. Results Seventy-four African patients (388 observations) and 528 Indian patients (1321 observations) were included in this pharmacokinetic analysis. A one-compartment model with first-order kinetics of absorption and elimination best described paromomycin in plasma. Bioavailability (relative standard error) was 1.17 (5.18%) times higher in Kenyan and Sudanese patients, and 2.46 (24.5%) times higher in Ethiopian patients, compared with Indian patients. Ethiopian patients had an approximately fourfold slower absorption rate constant of 0.446 h–1 (18.2%). Area under the plasma concentration-time curve for 24 h at steady-state (AUCτ,SS) for 15 mg/kg/day (median [interquartile range]) was higher in Kenya and Sudan (172.7 µg·h/mL [145.9–214.3]) and Ethiopia (230.1 µg·h/mL [146.3–591.2]) compared with India (97.26 µg·h/mL [80.83–123.4]). Conclusion The developed model provides detailed insight into the pharmacokinetic differences among Eastern African countries and India, however the resulting differences in paromomycin exposure do not seem to explain the geographical differences in paromomycin efficacy in the treatment of VL patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01036-8.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi) Africa, Nairobi, Kenya
| | - Gilbert Kokwaro
- KEMRI Wellcome Trust Programme, Nairobi, Kenya.,African Centre for Clinical Trials, Nairobi, Kenya
| | - Rashid Aman
- African Centre for Clinical Trials, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Mahmoud Mudawi
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Northern Border University, Arar, Saudi Arabia
| | - Brima M Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Asrat Hailu
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zewdu Hurissa
- College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Workagegnehu Hailu
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Samson Tesfaye
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yalemtsehay Mekonnen
- College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands
| | - Smita A Kshirsagar
- Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Jaya Chakravarty
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Madhukar Rai
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Shyam Sundar
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.
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9
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Mbui J, Olobo J, Omollo R, Solomos A, Kip AE, Kirigi G, Sagaki P, Kimutai R, Were L, Omollo T, Egondi TW, Wasunna M, Alvar J, Dorlo TPC, Alves F. Pharmacokinetics, Safety, and Efficacy of an Allometric Miltefosine Regimen for the Treatment of Visceral Leishmaniasis in Eastern African Children: An Open-label, Phase II Clinical Trial. Clin Infect Dis 2020; 68:1530-1538. [PMID: 30188978 PMCID: PMC6481997 DOI: 10.1093/cid/ciy747] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Convenient, safe, and effective treatments for visceral leishmaniasis in Eastern African children are lacking. Miltefosine, the only oral treatment, failed to achieve adequate efficacy, particularly in children, in whom linear dosing (2.5 mg/kg/day for 28 days) resulted in a 59% cure rate, with lower systemic exposure than in adults. METHODS We conducted a Phase II trial in 30 children with visceral leishmaniasis, aged 4-12 years, to test whether 28 days of allometric miltefosine dosing safely achieves a higher systemic exposure than linear dosing. RESULTS Miltefosine accumulated during treatment. Median areas under the concentration time curve from days 0-210 and plasma maximum concentration values were slightly higher than those reported previously for children on linear dosing, but not dose-proportionally. Miltefosine exposure at the start of treatment was increased, with higher median plasma concentrations on day 7 (5.88 versus 2.67 μg/mL). Concentration-time curves were less variable, avoiding the low levels of exposure observed with linear dosing. The 210-day cure rate was 90% (95% confidence interval, 73-98%), similar to that previously described in adults. There were 19 treatment-related adverse events (AEs), but none caused treatment discontinuation. There were 2 serious AEs: both were unrelated to treatment and both patients were fully recovered. CONCLUSIONS Allometric miltefosine dosing achieved increased and less-variable exposure than linear dosing, though not reaching the expected exposure levels. The new dosing regimen safely increased the efficacy of miltefosine for Eastern African children with visceral leishmaniasis. Further development of miltefosine should adopt allometric dosing in pediatric patients. CLINICAL TRIALS REGISTRATION NCT02431143.
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Affiliation(s)
- Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi
| | - Joseph Olobo
- Department of Medical Microbiology, Leishmaniasis Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Anke E Kip
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam
| | - George Kirigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi
| | | | | | - Lilian Were
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | | | | | - Jorge Alvar
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam
| | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
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10
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Couderc-Pétry M, Eléfant E, Wasunna M, Mwinga A, Kshirsagar NA, Strub-Wourgaft N. Inclusion of women susceptible to and becoming pregnant in preregistration clinical trials in low- and middle-income countries: A proposal for neglected tropical diseases. PLoS Negl Trop Dis 2020; 14:e0008140. [PMID: 32525876 PMCID: PMC7289336 DOI: 10.1371/journal.pntd.0008140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Elisabeth Eléfant
- Reference Center on Teratogenic Agents (CRAT), Armand-Trousseau Hospital, Paris, France
| | | | - Alwyn Mwinga
- Zambia AIDS Related Tuberculosis Project (Zambart), Lusaka, Zambia
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11
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Diro E, Edwards T, Ritmeijer K, Fikre H, Abongomera C, Kibret A, Bardonneau C, Soipei P, Mutinda B, Omollo R, van Griensven J, Zijlstra EE, Wasunna M, Alves F, Alvar J, Hailu A, Alexander N, Blesson S. Long term outcomes and prognostics of visceral leishmaniasis in HIV infected patients with use of pentamidine as secondary prophylaxis based on CD4 level: a prospective cohort study in Ethiopia. PLoS Negl Trop Dis 2019; 13:e0007132. [PMID: 30789910 PMCID: PMC6400407 DOI: 10.1371/journal.pntd.0007132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/05/2019] [Accepted: 01/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background The long-term treatment outcome of visceral leishmaniasis (VL) patients with HIV co-infection is complicated by a high rate of relapse, especially when the CD4 count is low. Although use of secondary prophylaxis is recommended, it is not routinely practiced and data on its effectiveness and safety are limited. Methods A prospective cohort study was conducted in Northwest Ethiopia from August 2014 to August 2017 (NCT02011958). HIV-VL patients were followed for up to 12 months. Patients with CD4 cell counts below 200/μL at the end of VL treatment received pentamidine prophylaxis starting one month after parasitological cure, while those with CD4 count ≥200 cells/μL were followed without secondary prophylaxis. Compliance, safety and relapse-free survival, using Kaplan-Meier analysis methods to account for variable time at risk, were summarised. Risk factors for relapse or death were analysed. Results Fifty-four HIV patients were followed. The probability of relapse-free survival at one year was 50% (95% confidence interval [CI]: 35–63%): 53% (30–71%) in 22 patients with CD4 ≥200 cells/μL without pentamidine prophylaxis and 46% (26–63%) in 29 with CD4 <200 cells/μL who started pentamidine. Three patients with CD4 <200 cells/μL did not start pentamidine. Amongst those with CD4 ≥200 cells/μL, VL relapse was an independent risk factor for subsequent relapse or death (adjusted rate ratio: 5.42, 95% CI: 1.1–25.8). Except for one case of renal failure which was considered possibly related to pentamidine, there were no drug-related safety concerns. Conclusion The relapse-free survival rate for VL patients with HIV was low. Relapse-free survival of patients with CD4 count <200cells/μL given pentamidine secondary prophylaxis appeared to be comparable to patients with a CD4 count ≥200 cells/μL not given prophylaxis. Patients with relapsed VL are at higher risk for subsequent relapse and should be considered a priority for secondary prophylaxis, irrespective of their CD4 count. Achieving parasitological cure at the end of visceral leishmaniasis (VL) treatment in HIV co-infected patients does not assure definitive cure, as the disease will recur within a year in many patients. In this cohort study, the probability of relapse-free survival at one-year was 50% in all patients. The use of monthly pentamidine infusion for those with lower CD4 counts (<200 cells/μL) at the time of VL cure appeared to result in a comparable relapse-free survival rate to those patients with higher CD4 count (≥200 cells/μL) who did not receive secondary prophylaxis. On the other hand, patients with a history of previous VL treatment (VL relapse) remained at high risk of relapse despite achieving CD4 count ≥200 cells/μL at the end of the VL treatment. While all VL patients with HIV co-infection may benefit from secondary prophylaxis, those with CD4 <200 cells/μL and previous history of treatment should be prioritized for secondary prophylaxis. New modalities for prevention of VL relapse in HIV patients should also be explored.
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Affiliation(s)
- Ermias Diro
- Leishmaniasis Research and Treatment Centre, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helina Fikre
- Leishmaniasis Research and Treatment Centre, University of Gondar, Gondar, Ethiopia
| | | | | | - Clélia Bardonneau
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Brian Mutinda
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | | | | | - Eduard E. Zijlstra
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Fabiana Alves
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Jorge Alvar
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Asrat Hailu
- Department of Microbiology, Immunology, and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Neal Alexander
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Séverine Blesson
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
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12
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Diro E, Blesson S, Edwards T, Ritmeijer K, Fikre H, Admassu H, Kibret A, Ellis SJ, Bardonneau C, Zijlstra EE, Soipei P, Mutinda B, Omollo R, Kimutai R, Omwalo G, Wasunna M, Tadesse F, Alves F, Strub-Wourgaft N, Hailu A, Alexander N, Alvar J. A randomized trial of AmBisome monotherapy and AmBisome and miltefosine combination to treat visceral leishmaniasis in HIV co-infected patients in Ethiopia. PLoS Negl Trop Dis 2019; 13:e0006988. [PMID: 30653490 PMCID: PMC6336227 DOI: 10.1371/journal.pntd.0006988] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 07/11/2018] [Accepted: 11/12/2018] [Indexed: 12/25/2022] Open
Abstract
Background Visceral leishmaniasis (VL) in human immunodeficiency virus (HIV) co-infected patients requires special case management. AmBisome monotherapy at 40 mg/kg is recommended by the World Health Organization. The objective of the study was to assess if a combination of a lower dose of AmBisome with miltefosine would show acceptable efficacy at the end of treatment. Methodology/Principal findings An open-label, non-comparative randomized trial of AmBisome (30 mg/kg) with miltefosine (100 mg/day for 28 days), and AmBisome monotherapy (40 mg/kg) was conducted in Ethiopian VL patients co-infected with HIV (NCT02011958). A sequential design was used with a triangular continuation region. The primary outcome was parasite clearance at day 29, after the first round of treatment. Patients with clinical improvement but without parasite clearance at day 29 received a second round of the allocated treatment. Efficacy was evaluated again at day 58, after completion of treatment. Recruitment was stopped after inclusion of 19 and 39 patients in monotherapy and combination arms respectively, as per pre-specified stopping rules. At D29, intention-to-treat efficacy in the AmBisome arm was 70% (95% CI 45–87%) in the unadjusted analysis, and 50% (95% CI 27–73%) in the adjusted analysis, while in the combination arm, it was 81% (95% CI 67–90%) and 67% (95% CI 48–82%) respectively. At D58, the adjusted efficacy was 55% (95% CI 32–78%) in the monotherapy arm, and 88% (95% CI 79–98%) in the combination arm. No major safety concerns related to the study medication were identified. Ten SAEs were observed within the treatment period, and 4 deaths unrelated to the study medication. Conclusions/Significance The extended treatment strategy with the combination regimen showed the highest documented efficacy in HIV-VL patients; these results support a recommendation of this regimen as first-line treatment strategy for HIV-VL patients in eastern Africa. Trial registration number www.clinicaltrials.govNCT02011958. Visceral Leishmaniasis is a complex parasitological disease and is particularly challenging to treat in patients coinfected with human immunodeficiency virus (HIV). Antimonial drugs used in first-line treatments for immunocompetent patients in eastern Africa are more toxic in immunocompromised patients. In 2010, a WHO expert committee recommended a lipid formulation of amphotericin B as first line treatment for HIV/VL co-infected patients, based on a single clinical trial conducted in Spain and empirical information obtained from scattered case reports using AmBisome (liposomal amphotericin B). In addition, Médecins Sans Frontières began a compassionate use regimen combining AmBisome and miltefosine a in a treatment centre in Northwest Ethiopia with encouraging results. Here, we report the results of a trial to assess the efficacy and safety of both the currently internationally recommended treatment of AmBisome monotherapy and the new AmBisome-miltefosine combination regimen, in Ethiopian patients. The results of this trial show that one course of treatment with either regimen could be insufficient to clear parasites in a high proportion of patients and that an extended treatment strategy, of administrating a second course of treatment, could lead to a high parasite clearance rate in patients treated with the combination regimen.
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Affiliation(s)
- Ermias Diro
- Leishmaniasis Research and Treatment Centre, University of Gondar, Gondar, Ethiopia
| | - Severine Blesson
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
- * E-mail:
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helina Fikre
- Leishmaniasis Research and Treatment Centre, University of Gondar, Gondar, Ethiopia
| | - Henok Admassu
- Abdurafi Health Centre, Médecins sans Frontières, Abdurafi, Ethiopia
| | - Aderajew Kibret
- Abdurafi Health Centre, Médecins sans Frontières, Abdurafi, Ethiopia
| | - Sally J. Ellis
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Clelia Bardonneau
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Eduard E. Zijlstra
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Brian Mutinda
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | | | | | | | | | - Fentahun Tadesse
- Neglected Tropical Diseases, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Fabiana Alves
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Nathalie Strub-Wourgaft
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Asrat Hailu
- Department of Microbiology, Immunology, and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Neal Alexander
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jorge Alvar
- Research & Development Department, Drugs for Neglected Diseases initiative, Geneva, Switzerland
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13
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Dorlo TPC, Kip AE, Younis BM, Ellis SJ, Alves F, Beijnen JH, Njenga S, Kirigi G, Hailu A, Olobo J, Musa AM, Balasegaram M, Wasunna M, Karlsson MO, Khalil EAG. Visceral leishmaniasis relapse hazard is linked to reduced miltefosine exposure in patients from Eastern Africa: a population pharmacokinetic/pharmacodynamic study. J Antimicrob Chemother 2018; 72:3131-3140. [PMID: 28961737 PMCID: PMC5890687 DOI: 10.1093/jac/dkx283] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 03/16/2017] [Accepted: 07/11/2017] [Indexed: 01/02/2023] Open
Abstract
Background Low efficacy of miltefosine in the treatment of visceral leishmaniasis was recently observed in Eastern Africa. Objectives To describe the pharmacokinetics and establish a pharmacokinetic/pharmacodynamic relationship for miltefosine in Eastern African patients with visceral leishmaniasis, using a time-to-event approach to model relapse of disease. Methods Miltefosine plasma concentrations from 95 patients (48 monotherapy versus 47 combination therapy) were included in the population pharmacokinetic model using non-linear mixed effects modelling. Subsequently a time-to-event model was developed to model the time of clinical relapse. Various summary pharmacokinetic parameters (various AUCs, Time > EC50, Time > EC90), normalized within each treatment arm to allow simultaneous analysis, were evaluated as relapse hazard-changing covariates. Results A two-compartment population model with first-order absorption fitted the miltefosine pharmacokinetic data adequately. Relative bioavailability was reduced (−74%, relative standard error 4.7%) during the first week of treatment of the monotherapy arm but only the first day of the shorter combination regimen. Time to the relapse of infection could be described using a constant baseline hazard (baseline 1.8 relapses/year, relative standard error 72.7%). Miltefosine Time > EC90 improved the model significantly when added in a maximum effect function on the baseline hazard (half maximal effect with Time > EC90 6.97 days for monotherapy). Conclusions Miltefosine drug exposure was found to be decreased in Eastern African patients with visceral leishmaniasis, due to a (transient) initial lower bioavailability. Relapse hazard was inversely linked to miltefosine exposure. Significantly lower miltefosine exposure was observed in children compared with adults, further urging the need for implementation of dose adaptations for children.
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Affiliation(s)
- Thomas P C Dorlo
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.,Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anke E Kip
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Brima M Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Sally J Ellis
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Simon Njenga
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Asrat Hailu
- Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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14
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Kip AE, Wasunna M, Alves F, Schellens JHM, Beijnen JH, Musa AM, Khalil EAG, Dorlo TPC. Macrophage Activation Marker Neopterin: A Candidate Biomarker for Treatment Response and Relapse in Visceral Leishmaniasis. Front Cell Infect Microbiol 2018; 8:181. [PMID: 29911074 PMCID: PMC5992270 DOI: 10.3389/fcimb.2018.00181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 02/27/2018] [Accepted: 05/09/2018] [Indexed: 01/15/2023] Open
Abstract
The Leishmania parasite resides and replicates within host macrophages during visceral leishmaniasis (VL). This study aimed to evaluate neopterin, a marker of macrophage activation, as possible pharmacodynamic biomarker to monitor VL treatment response and to predict long-term clinical relapse of VL. Following informed consent, 497 plasma samples were collected from East-African VL patients receiving a 28-day miltefosine monotherapy (48 patients) or 11-day combination therapy of miltefosine and liposomal amphotericin B (L-AMB, 48 patients). Neopterin was quantified with ELISA. Values are reported as median (inter-quartile range). Baseline neopterin concentrations were elevated in all VL patients at 98.8 (63.9–135) nmol/L compared to reported levels for healthy controls (<10 nmol/L). During the first treatment week, concentrations remained stable in monotherapy patients (p = 0.807), but decreased two-fold compared to baseline in the combination therapy patients (p < 0.01). In the combination therapy arm, neopterin concentrations increased significantly 1 day after L-AMB infusion compared to baseline for cured patients [137 (98.5–197) nmol/L, p < 0.01], but not for relapsing patients [84.4 (68.9–106) nmol/L, p = 0.96]. The neopterin parameter with the highest predictive power for VL relapse was a higher than 8% neopterin concentration increase between end of treatment and day 60 follow-up (ROC AUC 0.84), with a 93% sensitivity and 65% specificity. In conclusion, the identified neopterin parameter could be a potentially useful surrogate endpoint to identify patients in clinical trials at risk of relapse earlier during follow-up, possibly in a panel of biomarkers to increase its specificity.
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Affiliation(s)
- Anke E Kip
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Fabiana Alves
- Drug for Neglected Diseases Initiative, Geneva, Switzerland
| | - Jan H M Schellens
- Division of Pharmacoepidemiology & Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Department of Clinical Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, Netherlands.,Division of Pharmacoepidemiology & Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Department of Clinical Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital/the Netherlands Cancer Institute, Amsterdam, Netherlands
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15
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Bush JT, Wasunna M, Alves F, Alvar J, Olliaro PL, Otieno M, Sibley CH, Strub Wourgaft N, Guerin PJ. Systematic review of clinical trials assessing the therapeutic efficacy of visceral leishmaniasis treatments: A first step to assess the feasibility of establishing an individual patient data sharing platform. PLoS Negl Trop Dis 2017; 11:e0005781. [PMID: 28873394 PMCID: PMC5600407 DOI: 10.1371/journal.pntd.0005781] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 04/06/2017] [Revised: 09/15/2017] [Accepted: 07/06/2017] [Indexed: 12/14/2022] Open
Abstract
Background There are an estimated 200,000 to 400,000 cases of visceral leishmaniasis (VL) annually. A variety of factors are taken into account when considering the best therapeutic options to cure a patient and reduce the risk of resistance, including geographical area, malnourishment and HIV coinfection. Pooled analyses combine data from many studies to answer specific scientific questions that cannot be answered with individual studies alone. However, the heterogeneity of study design, data collection, and analysis often makes direct comparison difficult. Individual Participant Data (IPD) files can be standardised and analysed, allowing detailed analysis of this merged larger pool, but only a small fraction of systematic reviews and meta-analyses currently employ pooled analysis of IPD. We conducted a systematic literature review to identify published studies and studies reported in clinical trial registries to assess the feasibility of developing a VL data sharing platform to facilitate an IPD-based analysis of clinical trial data. Studies conducted between 1983 to 2015 that reported treatment outcome were eligible. Principal findings From the 2,271 documents screened, 145 published VL clinical trials were identified, with data from 26,986 patients. Methodologies varied for diagnosis and treatment outcomes, but overall the volume of data potentially available on different drugs and dose regimens identified hundreds or possibly thousands of patients per arm suitable for IPD pooled meta-analyses. Conclusions A VL data sharing platform would provide an opportunity to maximise scientific use of available data to enable assessment of treatment efficacy, contribute to evidence-based clinical management and guide optimal prospective data collection. Visceral leishmaniasis (VL) is a vector borne infectious disease caused by protozoan parasites transmitted by sand flies. The disease affects both immunocompetent and immunocompromised patients, predominantly occurring in remote regions in specific areas of Africa, Asia and South America. There are an estimated 200,000 to 400,000 cases each year, resulting in 20,000 to 40,000 deaths. Few therapeutic options are available, and these are typically expensive, not adapted for field use and cause life-threatening side effects. Treatment of the disease is further complicated by apparent variation in drug efficacy in patients from different regions. A comprehensive understanding of treatment outcomes is essential to ensure more effective treatment and control of VL. This systematic review was undertaken to determine whether sufficient relevant data are available to warrant creation of a data sharing platform for harmonisation and comparison of VL clinical trials. We identified 145 published VL clinical trials, which together have enrolled 26,986 patients. There was sufficient consistency in the trial methods to support pooling of these individual patient data. The findings of this review suggest that a VL data sharing platform would enable meaningful meta-analysis of VL treatment trials, which could inform treatment allocation, further drug development, and guide improved disease control.
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Affiliation(s)
- Jacob T. Bush
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and Global Health, Oxford, United Kingdom
| | | | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Piero L. Olliaro
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Special Programme on Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
| | - Michael Otieno
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and Global Health, Oxford, United Kingdom
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | - Carol Hopkins Sibley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and Global Health, Oxford, United Kingdom
- Department of Genome Sciences, University of Washington, Seattle, Washington, United States of America
| | | | - Philippe J. Guerin
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and Global Health, Oxford, United Kingdom
- * E-mail: (PG); (NS)
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Kimutai R, Musa AM, Njoroge S, Omollo R, Alves F, Hailu A, Khalil EAG, Diro E, Soipei P, Musa B, Salman K, Ritmeijer K, Chappuis F, Rashid J, Mohammed R, Jameneh A, Makonnen E, Olobo J, Okello L, Sagaki P, Strub N, Ellis S, Alvar J, Balasegaram M, Alirol E, Wasunna M. Safety and Effectiveness of Sodium Stibogluconate and Paromomycin Combination for the Treatment of Visceral Leishmaniasis in Eastern Africa: Results from a Pharmacovigilance Programme. Clin Drug Investig 2017; 37:259-272. [PMID: 28066878 PMCID: PMC5315726 DOI: 10.1007/s40261-016-0481-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION In 2010, WHO recommended a new first-line treatment for visceral leishmaniasis (VL) in Eastern Africa. The new treatment, a combination of intravenous (IV) or intramuscular (IM) sodium stibogluconate (SSG) and IM paromomycin (PM) was an improvement over SSG monotherapy, the previous first-line VL treatment in the region. To monitor the new treatment's safety and effectiveness in routine clinical practice a pharmacovigilance (PV) programme was developed. METHODS A prospective PV cohort was developed. Regulatory approval was obtained in Sudan, Kenya, Uganda and Ethiopia. Twelve sentinel sites sponsored by the Ministries of Health, Médecins Sans Frontières (MSF) and Drugs for Neglected Diseases initiative (DNDi) participated. VL patients treated using the new treatment were consented and included in a common registry that collected demographics, baseline clinical characteristics, adverse events, serious adverse events and treatment outcomes. Six-monthly periodic safety update reports (PSUR) were prepared and reviewed by a PV steering committee. RESULTS Overall 3126 patients were enrolled: 1962 (62.7%) from Sudan, 652 (20.9%) from Kenya, 322 (10.3%) from Ethiopia and 190 (6.1%) from Uganda. Patients were mostly male children (68.1%, median age 11 years) with primary VL (97.8%). SSG-PM initial cure rate was 95.1%; no geographical differences were noted. HIV/VL co-infected patients and patients older than 50 years had initial cure rates of 56 and 81.4%, respectively, while 1063 (34%) patients had at least one adverse event (AE) during treatment and 1.92% (n = 60) had a serious adverse event (SAE) with a mortality of 1.0% (n = 32). There were no serious unexpected adverse drug reactions. CONCLUSIONS This first regional PV programme in VL supports SSG-PM combination as first-line treatment for primary VL in Eastern Africa. SSG-PM was effective and safe except in HIV/VL co-infected or older patients. Active PV surveillance of targeted safety, effectiveness and key VL outcomes such us VL relapse, PKDL and HIV/VL co-infection should continue and PV data integrated to national and WHO PV databases.
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Affiliation(s)
- Robert Kimutai
- Centre for Clinical Research, Kenya Medical Research Institute, PO Box 20778-00202, Off Mbagathi Rd, Nairobi, Kenya.
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya.
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Simon Njoroge
- Centre for Clinical Research, Kenya Medical Research Institute, PO Box 20778-00202, Off Mbagathi Rd, Nairobi, Kenya
| | - Raymond Omollo
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya
| | - Fabiana Alves
- Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | - Asrat Hailu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - Peninah Soipei
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya
| | - Brima Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Khalid Salman
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Francois Chappuis
- Médecins Sans Frontières, Geneva, Switzerland
- Geneva University Hospitals, Geneva, Switzerland
| | - Juma Rashid
- Centre for Clinical Research, Kenya Medical Research Institute, PO Box 20778-00202, Off Mbagathi Rd, Nairobi, Kenya
| | | | - Asfaw Jameneh
- Arba Minch Hospital, Regional Health Bureau of SNNPR State, Arba Minch, Ethiopia
| | - Eyasu Makonnen
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | - Nathalie Strub
- Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | - Sally Ellis
- Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | - Jorge Alvar
- Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | | | - Emilie Alirol
- Médecins Sans Frontières, Geneva, Switzerland
- Geneva University Hospitals, Geneva, Switzerland
| | - Monique Wasunna
- Centre for Clinical Research, Kenya Medical Research Institute, PO Box 20778-00202, Off Mbagathi Rd, Nairobi, Kenya
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya
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Wasunna M, Musa A, Hailu A, Khalil EAG, Olobo J, Juma R, Wells S, Alvar J, Balasegaram M. The Leishmaniasis East Africa Platform (LEAP): strengthening clinical trial capacity in resource-limited countries to deliver new treatments for visceral leishmaniasis. Trans R Soc Trop Med Hyg 2016; 110:321-3. [PMID: 27268714 PMCID: PMC4926319 DOI: 10.1093/trstmh/trw031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/18/2016] [Indexed: 11/26/2022] Open
Abstract
Visceral leishmaniasis is a neglected tropical disease endemic in East Africa where improved patient-adapted treatments are needed. The Leishmaniasis East Africa Platform (LEAP) was created in 2003 to strengthen clinical research capacity, serve as a base for training, and evaluate and facilitate implementation of new treatments. Major infrastructure upgrades and personnel training have been carried out. A short course of Sodium Stibogluconate and Paramomycin (SSG&PM) was evaluated and is now first-line treatment in the region; alternative treatments have also been assessed. LEAP can serve as a successful model of collaboration between different partners and countries when conducting clinical research in endemic countries to international standards.
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Affiliation(s)
- Monique Wasunna
- Drugs for Neglected Diseases initiative, KNH 00202, Nairobi, Kenya Centre for Clinical Research, Kenya Medical Research Institute, KNH 00202, Nairobi, Kenya
| | - Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan
| | - Asrat Hailu
- Addis Ababa University, Addis Ababa 1000, Ethiopia
| | - Eltahir A G Khalil
- Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan
| | | | - Rashid Juma
- Centre for Clinical Research, Kenya Medical Research Institute, KNH 00202, Nairobi, Kenya
| | - Susan Wells
- Drugs for Neglected Diseases initiative, Geneva CH1202, Switzerland
| | - Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva CH1202, Switzerland
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Omollo R, Ochieng M, Mutinda B, Omollo T, Owiti R, Okeyo S, Wasunna M, Edwards T. Innovative approaches to clinical data management in resource limited settings using open-source technologies. PLoS Negl Trop Dis 2014; 8:e3134. [PMID: 25210976 PMCID: PMC4161312 DOI: 10.1371/journal.pntd.0003134] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Raymond Omollo
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Michael Ochieng
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Brian Mutinda
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Truphosa Omollo
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Rhoda Owiti
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Seth Okeyo
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative Africa, Regional Office, Nairobi, Kenya; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene &Tropical Medicine, London, United Kingdom
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Mbui J, Wasunna M, Balasegaram M, Laussermayer A, Juma R, Njenga SN, Kirigi G, Riongoita M, de la Tour R, van Peteghem J, Omollo R, Chappuis F. Validation of two rapid diagnostic tests for visceral leishmaniasis in Kenya. PLoS Negl Trop Dis 2013; 7:e2441. [PMID: 24086782 PMCID: PMC3784478 DOI: 10.1371/journal.pntd.0002441] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 08/11/2013] [Indexed: 12/02/2022] Open
Abstract
Background Visceral leishmaniasis (VL) is a systemic parasitic disease that is fatal unless treated. In Kenya, national VL guidelines rely on microscopic examination of spleen aspirate to confirm diagnosis. As this procedure is invasive, it cannot be safely implemented in peripheral health structures, where non-invasive, accurate, easy to use diagnostic tests are needed. Methodology We evaluated the sensitivity, specificity and predictive values of two rapid diagnostic tests (RDT), DiaMed IT LEISH and Signal-KA, among consecutive patients with clinical suspicion of VL in two treatment centres located in Baringo and North Pokot District, Rift Valley province, Kenya. Microscopic examination of spleen aspirate was the reference diagnostic standard. Patients were prospectively recruited between May 2010 and July 2011. Principal Findings Of 251 eligible patients, 219 patients were analyzed, including 131 VL and 88 non-VL patients. The median age of VL patients was 16 years with predominance of males (66%). None of the tested VL patients were co-infected with HIV. Sensitivity and specificity of the DiaMed IT LEISH were 89.3% (95%CI: 82.7–94%) and 89.8% (95%CI: 81.5–95.2%), respectively. The Signal KA showed trends towards lower sensitivity (77.1%; 95%CI: 68.9–84%) and higher specificity (95.5%; 95%CI: 88.7–98.7%). Combining the tests did not improve the overall diagnostic performance, as all patients with a positive Signal KA were also positive with the DiaMed IT LEISH. Conclusion/Significance The DiaMed IT LEISH can be used to diagnose VL in Kenyan peripheral health facilities where microscopic examination of spleen aspirate or sophisticated serological techniques are not feasible. There is a crucial need for an improved RDT for VL diagnosis in East Africa. Visceral Leishmaniasis (VL) is potentially fatal if not treated promptly. Its diagnosis is based on the presence of parasites in spleen or bone marrow aspirates. These are invasive and risky procedures. Simple, rapid and non-invasive diagnostic tests are needed, notably in rural settings. We evaluated 2 rapid diagnostic tests, DiaMed IT LEISH and Signal KA for VL diagnosis, using splenic aspiration as the gold standard. The study was carried out in 2 hospitals located in Rift Valley province in Kenya, where VL is endemic. A total of 219 patients underwent splenic aspiration; 131 were positive and 88 were negative. DiaMed IT LEISH was able to correctly identify 117 of the positive cases, yielding a sensitivity of 89.3%, while Signal KA correctly identified 101, corresponding to a sensitivity of 77.1%. DiaMed IT LEISH was able to correctly label 79 of the 88 negative patients, yielding a specificity of 89.2%, while the Signal KA correctly labelled 84 of them, giving it a specificity of 95.5%. In conclusion, our study showed that rapid diagnostic tests can be used to diagnose VL in Kenyan rural health facilities, where splenic aspiration cannot be carried out safely.
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Affiliation(s)
- Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Monique Wasunna
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | | | | | - Rashid Juma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - George Kirigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mark Riongoita
- Médecins Sans Frontières, Operational Centre, Geneva, Switzerland
| | | | | | - Raymond Omollo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | - François Chappuis
- Médecins Sans Frontières, Operational Centre, Geneva, Switzerland
- Geneva University Hospitals, Geneva, Switzerland
- * E-mail:
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Odiwuor S, Muia A, Magiri C, Maes I, Kirigi G, Dujardin JC, Wasunna M, Mbuchi M, Auwera GVD. Identification of Leishmania tropica from micro-foci of cutaneous leishmaniasis in the Kenyan Rift Valley. Pathog Glob Health 2013; 106:159-65. [PMID: 23265373 DOI: 10.1179/2047773212y.0000000015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
We performed diagnosis and species identification of parasites in lesion samples from suspected cutaneous leishmaniasis patients in four villages, three of which are in a known Leishmania tropica endemic region in Kenya. Samples were analyzed both by microscopy and PCR for Leishmania, and typed by an assay using four ribosomal DNA-based species-identification PCRs. The lesions were demonstrated to be caused by L. tropica, which confirms the re-emergence of cutaneous leishmaniasis from this species after a period of reduced incidence in the endemic zone. Our report highlights the importance of an intervention and sustained Leishmania control program.
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Affiliation(s)
- Samwel Odiwuor
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Cunningham J, Hasker E, Das P, El Safi S, Goto H, Mondal D, Mbuchi M, Mukhtar M, Rabello A, Rijal S, Sundar S, Wasunna M, Adams E, Menten J, Peeling R, Boelaert M. A global comparative evaluation of commercial immunochromatographic rapid diagnostic tests for visceral leishmaniasis. Clin Infect Dis 2012; 55:1312-9. [PMID: 22942208 PMCID: PMC3478143 DOI: 10.1093/cid/cis716] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Accuracy of rapid diagnostic tests was high in the Indian subcontinent; however, in Brazilian and East African samples, reduced sensitivity suggests that several cannot be used alone to exclude visceral leishmaniasis. Data on ease of use and performance using whole blood and in human immunodeficiency virus coinfections is needed. Background. Poor access to diagnosis stymies control of visceral leishmaniasis (VL). Antibody-detecting rapid diagnostic tests (RDTs) can be performed in peripheral health settings. However, there are many brands available and published reports of variable accuracy. Methods. Commercial VL RDTs containing bound rK39 or rKE16 antigen were evaluated using archived human sera from confirmed VL cases (n = 750) and endemic non-VL controls (n = 754) in the Indian subcontinent (ISC), Brazil, and East Africa to assess sensitivity and specificity with 95% confidence intervals. A subset of RDTs were also evaluated after 60 days’ heat incubation (37°C, 45°C). Interlot and interobserver variability was assessed. Results. All test brands performed well against ISC panels (sensitivity range, 92.8%–100%; specificity range, 96%–100%); however, sensitivity was lower against Brazil and East African panels (61.5%–91% and 36.8%–87.2%, respectively). Specificity was consistently > 95% in Brazil and ranged between 90.8% and 98% in East Africa. Performance of some products was adversely affected by high temperatures. Agreement between lots and readers was good to excellent (κ > 0.73–0.99). Conclusions. Diagnostic accuracy of VL RDTs varies between the major endemic regions. Many tests performed well and showed good heat stability in the ISC; however, reduced sensitivity against Brazilian and East African panels suggests that in these regions, used alone, several RDTs are inadequate for excluding a VL diagnosis. More research is needed to assess ease of use and to compare performance using whole blood instead of serum and in patients coinfected with human immunodeficiency virus.
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Affiliation(s)
- Jane Cunningham
- UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland.
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Musa A, Khalil E, Hailu A, Olobo J, Balasegaram M, Omollo R, Edwards T, Rashid J, Mbui J, Musa B, Abuzaid AA, Ahmed O, Fadlalla A, El-Hassan A, Mueller M, Mucee G, Njoroge S, Manduku V, Mutuma G, Apadet L, Lodenyo H, Mutea D, Kirigi G, Yifru S, Mengistu G, Hurissa Z, Hailu W, Weldegebreal T, Tafes H, Mekonnen Y, Makonnen E, Ndegwa S, Sagaki P, Kimutai R, Kesusu J, Owiti R, Ellis S, Wasunna M. Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in East Africa: a randomised controlled trial. PLoS Negl Trop Dis 2012; 6:e1674. [PMID: 22724029 PMCID: PMC3378617 DOI: 10.1371/journal.pntd.0001674] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [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: 10/11/2011] [Accepted: 04/23/2012] [Indexed: 11/26/2022] Open
Abstract
Background Alternative treatments for visceral leishmaniasis (VL) are required in East Africa. Paromomycin sulphate (PM) has been shown to be efficacious for VL treatment in India. Methods A multi-centre randomized-controlled trial (RCT) to compare efficacy and safety of PM (20 mg/kg/day for 21 days) and PM plus sodium stibogluconate (SSG) combination (PM, 15 mg/kg/day and SSG, 20 mg/kg/day for 17 days) with SSG (20 mg/kg/day for 30 days) for treatment of VL in East Africa. Patients aged 4–60 years with parasitologically confirmed VL were enrolled, excluding patients with contraindications. Primary and secondary efficacy outcomes were parasite clearance at 6-months follow-up and end of treatment, respectively. Safety was assessed mainly using adverse event (AE) data. Findings The PM versus SSG comparison enrolled 205 patients per arm with primary efficacy data available for 198 and 200 patients respectively. The SSG & PM versus SSG comparison enrolled 381 and 386 patients per arm respectively, with primary efficacy data available for 359 patients per arm. In Intention-to-Treat complete-case analyses, the efficacy of PM was significantly lower than SSG (84.3% versus 94.1%, difference = 9.7%, 95% confidence interval, CI: 3.6 to 15.7%, p = 0.002). The efficacy of SSG & PM was comparable to SSG (91.4% versus 93.9%, difference = 2.5%, 95% CI: −1.3 to 6.3%, p = 0.198). End of treatment efficacy results were very similar. There were no apparent differences in the safety profile of the three treatment regimens. Conclusion The 17 day SSG & PM combination treatment had a good safety profile and was similar in efficacy to the standard 30 day SSG treatment, suggesting suitability for VL treatment in East Africa. Clinical Trials Registration www.clinicaltrials.govNCT00255567 Visceral leishmaniasis (VL) is a parasitic disease with about 500,000 new cases each year and is fatal if untreated. The current standard therapy involves long courses, has toxicity and there is evidence of increasing resistance. New and better treatment options are urgently needed. Recently, the antibiotic paromomycin (PM) was tested and registered in India to treat this disease, but the same dose of PM monotherapy evaluated and registered in India was not efficacious in Sudan. This article reports the results of a clinical trial to test the effectiveness of injectable PM either alone (in a higher dose) or in combination with sodium stibogluconate (SSG) against the standard SSG monotherapy treatment in four East African countries—Sudan, Kenya, Ethiopia and Uganda. The study showed that the combination of SSG &PM was as efficacious and safe as the standard SSG treatment, with the advantages of being cheaper and requiring only 17 days rather than 30 days of treatment. In March 2010, a WHO Expert Committee recommended the use of the SSG & PM combination as a first line treatment for VL in East Africa.
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Affiliation(s)
- Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Eltahir Khalil
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Asrat Hailu
- Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Manica Balasegaram
- Médecins Sans Frontières-Holland, Amsterdam, The Netherlands
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Raymond Omollo
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Juma Rashid
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Brima Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Osama Ahmed
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Ahmed El-Hassan
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Marius Mueller
- Médecins Sans Frontières-Holland, Amsterdam, The Netherlands
| | - Geoffrey Mucee
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njoroge
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Veronica Manduku
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Geoffrey Mutuma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lilian Apadet
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Hudson Lodenyo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Dedan Mutea
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - George Kirigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | | | - Teklu Weldegebreal
- Arba Minch Hospital, Regional Health Bureau of SNNPR State, Arba Minch, Ethiopia
| | - Hailemariam Tafes
- Arba Minch Hospital, Regional Health Bureau of SNNPR State, Arba Minch, Ethiopia
| | | | | | | | | | - Robert Kimutai
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Kesusu
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rhoda Owiti
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sally Ellis
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail:
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Omollo R, Alexander N, Edwards T, Khalil EAG, Younis BM, Abuzaid AA, Wasunna M, Njoroge N, Kinoti D, Kirigi G, Dorlo TPC, Ellis S, Balasegaram M, Musa AM. Safety and efficacy of miltefosine alone and in combination with sodium stibogluconate and liposomal amphotericin B for the treatment of primary visceral leishmaniasis in East Africa: study protocol for a randomized controlled trial. Trials 2011; 12:166. [PMID: 21718522 PMCID: PMC3155829 DOI: 10.1186/1745-6215-12-166] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [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] [Received: 03/21/2011] [Accepted: 06/30/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment options for visceral leishmaniasis (VL) in East Africa are far from satisfactory due to cost, toxicity, prolonged treatment duration or emergence of parasite resistance. Hence there is a need to explore alternative treatment protocols such as miltefosine alone or in combinations including miltefosine, sodium stibogluconate (SSG) or liposomal amphotericin B. The aim of this trial is to identify regimen(s) which are sufficiently promising for future trials in East Africa. METHODS/DESIGN A phase II randomized, parallel arm, open-labelled trial is being conducted to assess the efficacy of each of the three regimens: liposomal amphotericin B with SSG, Liposomal amphotericin B with miltefosine and miltefosine alone. The primary endpoint is cure at day 28 with secondary endpoint at day 210 (6 months). Initial cure is a single composite measure based on parasitologic evaluation (bone marrow, spleen or lymph node aspirate) and clinical assessment. Repeated interim analyses have been planned after recruitment of 15 patients in each arm with a maximum sample size of 63 for each. These will follow group-sequential methods (the triangular test) to identify when a regimen is inadequate (<75% efficacy) or adequate (>90% efficacy). We describe a method to ensure consistency of the sequential analysis of day 28 cure with the non-sequential analysis of day 210 cure. DISCUSSION A regimen with adequate efficacy would be a candidate for treatment of VL with reasonable costs. The design allows repeated testing throughout the trial recruitment period while maintaining good statistical properties (Type I & II error rates) and reducing the expected sample sizes. TRIAL REGISTRATION ClinicalTrials.gov: NCT01067443.
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Affiliation(s)
- Raymond Omollo
- Drugs for Neglected Diseases initiative (DNDi) Africa, Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Neal Alexander
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Eltahir AG Khalil
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Brima M Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Abuzaid A Abuzaid
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi) Africa, Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Njenga Njoroge
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Dedan Kinoti
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - George Kirigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Thomas PC Dorlo
- Division of Infectious Diseases, Tropical Medicine & AIDS, Academic Medical Center, Amsterdam, the Netherlands
- Department of Pharmacy & Pharmacology, Slotervaart Hospital, Amsterdam, the Netherlands
| | | | | | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
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Musa AM, Younis B, Fadlalla A, Royce C, Balasegaram M, Wasunna M, Hailu A, Edwards T, Omollo R, Mudawi M, Kokwaro G, El-Hassan A, Khalil E. Paromomycin for the treatment of visceral leishmaniasis in Sudan: a randomized, open-label, dose-finding study. PLoS Negl Trop Dis 2010; 4:e855. [PMID: 21049063 PMCID: PMC2964291 DOI: 10.1371/journal.pntd.0000855] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 09/24/2010] [Indexed: 11/21/2022] Open
Abstract
Background A recent study has shown that treatment of visceral leishmaniasis (VL) with the standard dose of 15 mg/kg/day of paromomycin sulphate (PM) for 21 days was not efficacious in patients in Sudan. We therefore decided to test the efficacy of paramomycin for a longer treatment duration (15 mg/kg/day for 28 days) and at the higher dose of 20 mg/kg/day for 21 days. Methods This randomized, open-label, dose-finding, phase II study assessed the two above high-dose PM treatment regimens. Patients with clinical features and positive bone-marrow aspirates for VL were enrolled. All patients received their assigned courses of PM intramuscularly and adverse events were monitored. Parasite clearance in bone-marrow aspirates was tested by microscopy at end of treatment (EOT, primary efficacy endpoint), 3 months (in patients who were not clinically well) and 6 months after EOT (secondary efficacy endpoint). Pharmacokinetic data were obtained from a subset of patients weighing over 30 kg. Findings 42 patients (21 per group) aged between 4 and 60 years were enrolled. At EOT, 85% of patients (95% confidence interval [CI]: 63.7% to 97.0%) in the 20 mg/kg/day group and 90% of patients (95% CI: 69.6% to 98.8%) in the 15 mg/kg/day group had parasite clearance. Six months after treatment, efficacy was 80.0% (95% CI: 56.3% to 94.3%) and 81.0% (95% CI: 58.1% to 94.6%) in the 20 mg/kg/day and 15 mg/kg/day groups, respectively. There were no serious adverse events. Pharmacokinetic profiles suggested a difference between the two doses, although numbers of patients recruited were too few to make it significant (n = 3 and n = 6 in the 20 mg/kg/day and 15 mg/kg/day groups, respectively). Conclusion Data suggest that both high dose regimens were more efficacious than the standard 15 mg/kg/day PM for 21 days and could be further evaluated in phase III studies in East Africa. Trial Registration ClinicalTrials.gov NCT00255567 Visceral leishmaniasis (VL) is a parasitic disease transmitted through the bite of sandflies. The WHO estimates 500,000 new cases of VL each year, with more than 90% of cases occurring in Southeast Asia, East Africa, and South America. If left untreated, VL can be fatal. We had previously conducted a large multi-center study in Sudan, East Africa, to assess the efficacy of paromomycin (PM) alone or in combination with sodium stibogluconate. Clinical studies in India have shown that 15 mg/kg/day PM for 21 days was an effective cure. However, the same treatment regimen was not efficacious in two study sites in Sudan. Here, our aim was to assess two high-dose regimens of PM in Sudan: 15 mg/kg/day for 28 days and 20 mg/kg/day for 21 days. The results suggest that, at these total doses, PM is more efficacious than when given daily at 15 mg/kg for 21 days, and that high doses are required to treat VL in Sudan. Efficacy of 20 mg/kg/day PM for 21 days is currently being evaluated in a prospective, comparative phase III trial in East Africa.
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Affiliation(s)
- Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan.
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Hailu A, Musa A, Wasunna M, Balasegaram M, Yifru S, Mengistu G, Hurissa Z, Hailu W, Weldegebreal T, Tesfaye S, Makonnen E, Khalil E, Ahmed O, Fadlalla A, El-Hassan A, Raheem M, Mueller M, Koummuki Y, Rashid J, Mbui J, Mucee G, Njoroge S, Manduku V, Musibi A, Mutuma G, Kirui F, Lodenyo H, Mutea D, Kirigi G, Edwards T, Smith P, Muthami L, Royce C, Ellis S, Alobo M, Omollo R, Kesusu J, Owiti R, Kinuthia J. Geographical variation in the response of visceral leishmaniasis to paromomycin in East Africa: a multicentre, open-label, randomized trial. PLoS Negl Trop Dis 2010; 4:e709. [PMID: 21049059 PMCID: PMC2964287 DOI: 10.1371/journal.pntd.0000709] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 04/21/2010] [Indexed: 12/03/2022] Open
Abstract
Background Visceral leishmaniasis (VL) is a major health problem in developing countries. The untreated disease is fatal, available treatment is expensive and often toxic, and drug resistance is increasing. Improved treatment options are needed. Paromomycin was shown to be an efficacious first-line treatment with low toxicity in India. Methods This was a 3-arm multicentre, open-label, randomized, controlled clinical trial to compare three treatment regimens for VL in East Africa: paromomycin sulphate (PM) at 15 mg/kg/day for 21 days versus sodium stibogluconate (SSG) at 20 mg/kg/day for 30 days; and the combination of both dose regimens for 17 days. The primary efficacy endpoint was cure based on parasite-free tissue aspirates taken 6 months after treatment. Findings Overall, 135 patients per arm were enrolled at five centres in Sudan (2 sites), Kenya (1) and Ethiopia (2), when the PM arm had to be discontinued due to poor efficacy. The trial has continued with the higher dose of PM as well as the combination of PM and SSG arms. These results will be reported later. Baseline patient characteristics were similar among treatment arms. The overall cure with PM was significantly inferior to that with SSG (63.8% versus 92.2%; difference 28.5%, 95%CI 18.8% to 38.8%, p<0.001). The efficacy of PM varied among centres and was significantly lower in Sudan (14.3% and 46.7%) than in Kenya (80.0%) and Ethiopia (75.0% and 96.6%). No major safety issues with PM were identified. Conclusion The efficacy of PM at 15 mg/kg/day for 21 days was inadequate, particularly in Sudan. The efficacy of higher doses and the combination treatment warrant further studies. Visceral leishmaniasis (VL) is a fatal parasitic disease with 500,000 new cases each year according to WHO estimates. New and better treatment options are urgently needed in disease endemic areas due to the long courses, toxicity and development of resistance to current treatments. Recently, the antibiotic paromomycin was tested and registered in India to treat this disease. The current study describes a clinical trial to test the effectiveness of injectable paromomycin, either alone or in combination with the standard drug sodium stibogluconate in three East African countries—Sudan, Kenya and Ethiopia. The study showed that at the same paromomycin dose that was successfully used and registered in India, a far poorer outcome was obtained, particularly in Sudan, suggesting that there are either differences in the patients ability to respond to the drug or in the susceptibility of parasites in East Africa compared with those in India. However, no major safety concerns were noted with the treatment. Further research was initiated to see if a higher dose of paromomycin would perform better, especially in Sudan. The results of this and the performance of the combination arm will be reported later. Our study highlights the importance of considering geographical differences to treatment responses.
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Affiliation(s)
- Asrat Hailu
- Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Monique Wasunna
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail:
| | - Manica Balasegaram
- Medecins Sans Frontieres-Holland, Amsterdam, The Netherlands
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | - Getahun Mengistu
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | - Teklu Weldegebreal
- Arba Minch Hospital, Regional Health Bureau of SNNP state, Arba Minch, Ethiopia
| | - Samson Tesfaye
- Arba Minch Hospital, Regional Health Bureau of SNNP state, Arba Minch, Ethiopia
| | | | - Eltahir Khalil
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Osama Ahmed
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Ahmed El-Hassan
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Muzamil Raheem
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Marius Mueller
- Medecins Sans Frontieres-Holland, Amsterdam, The Netherlands
| | - Yousif Koummuki
- Medecins Sans Frontieres-Holland, Amsterdam, The Netherlands
| | - Juma Rashid
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Geoffrey Mucee
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njoroge
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Veronica Manduku
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Alice Musibi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Geoffrey Mutuma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Fredrick Kirui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Hudson Lodenyo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Dedan Mutea
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - George Kirigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tansy Edwards
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Smith
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lawrence Muthami
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Catherine Royce
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Sally Ellis
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Moses Alobo
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Raymond Omollo
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Josephine Kesusu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rhoda Owiti
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - John Kinuthia
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
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Fox MP, McCoy K, Larson BA, Rosen S, Bii M, Sigei C, Shaffer D, Sawe F, Wasunna M, Simon JL. Improvements in physical wellbeing over the first two years on antiretroviral therapy in western Kenya. AIDS Care 2010; 22:137-45. [PMID: 20390492 DOI: 10.1080/09540120903038366] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Improvements in physical wellbeing during the first six months on antiretroviral therapy (ART) are well known, but little is known regarding long-term follow-up. We conducted a prospective cohort study among 222 HIV-positive adult tea plantation workers in western Kenya to assess wellbeing over their first two years on ART. Study subjects completed a standardized questionnaire during repeat ART clinic visits. A 30-day recall period was used to elicit the number of days when subjects experienced poor health and the number of days that pain made it difficult to complete usual activities at home and work. A seven-day recall period was used to assess the severity of bodily pain, nausea, fatigue, and rash. Prevalence of most symptoms declined over time. A median of seven days poor health during the first month on ART declined to three days in the 24th month (p=0.043). For pain making usual activities difficult, a median of seven days during the first month on ART fell to zero by 12 months (p< or =0.0001) but increased to three days by two years. Any bodily pain (range 59-83%) and fatigue (range 51-84%) over the past seven days were common through two years. However, pain and fatigue often over the past seven days declined over two years (from 24-10% (p=0.067) and 41-15% (p=0.002)). Skin rash was rare at all times, though higher at two years (8.6%) than any other time. Initial improvements in physical wellbeing were sustained over two years, however, increased pain and skin rash at year two may indicate problems as treatment programs mature. These improvements in physical wellbeing will be important in sustaining the long-term success of HIV treatment programs.
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Affiliation(s)
- Matthew P Fox
- Department of International Health, Center for Global Health and Development, School of Public Health, Boston University, Boston, MA, USA.
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Arroyo MA, Sateren WB, Foglia G, Kibaya R, Langat L, Wasunna M, Bautista CT, Scott PT, Shaffer DN, Robb ML, Michael NL, Birx DL, McCutchan FE. Short communication: HIV type 1 genetic diversity among tea plantation workers in Kericho, Kenya. AIDS Res Hum Retroviruses 2009; 25:1061-4. [PMID: 19943788 DOI: 10.1089/aid.2009.0092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In preparation for HIV-1 vaccine trials in Kenya, 2801 study volunteers, from a tea plantation in Kericho, were recruited as part of a prospective vaccine cohort development study. Cryopreserved plasma was available from 401 HIV-positive volunteers, and was the source of viral RNA for genotyping by the multiregion hybridization assay (MHA). Logistic regression was performed to determine association of risk factors and HIV-1 recombinant and dual infections. At baseline, HIV-1 subtype A was the dominant circulating pure subtype (56%), followed by subtype D (10%) and C (5%). Recombinant HIV-1 strains accounted for almost one-third of all infections (29%), with 7% infected with a dual strain of the HIV-1 variants described. A higher number of HIV-1 recombinant and dual infections was observed among volunteers who were 18-24 and 25-29 years of age, affiliated with the Luo tribe, had been married two or more times, reported not being circumcised, and had STI symptoms in the past 6 months. Adjusted odds ratios (AOR) significantly associated with HIV-1 recombinant and dual infection were age difference from current spouse (5-9 years; AOR = 2.5, 95% CI = 1.2-5.3 and > or = 10 years; AOR = 3.1, 95% CI = 1.5-6.4) and reported STI symptoms in the past 6 months (AOR = 4.8, 95% CI = 2.0-11.6), respectively. In conclusion, our results suggest that there is considerable heterogeneity with respect to HIV-1 subtype diversity in this population that should be considered in the planning for future vaccine trials in the region.
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Affiliation(s)
- Miguel A. Arroyo
- Division of Retrovirology, Walter Reed Army Institute of Research/U.S. Military HIV Research Program (MHRP), Rockville, Maryland 20850
| | - Warren B. Sateren
- Division of Retrovirology, Walter Reed Army Institute of Research/U.S. Military HIV Research Program (MHRP), Rockville, Maryland 20850
| | | | - Rukia Kibaya
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Christian T. Bautista
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, 20850
| | - Paul T. Scott
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, 20850
| | | | - Merlin L. Robb
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, 20850
| | - Nelson L. Michael
- Division of Retrovirology, Walter Reed Army Institute of Research/U.S. Military HIV Research Program (MHRP), Rockville, Maryland 20850
| | - Deborah L. Birx
- Division of Retrovirology, Walter Reed Army Institute of Research/U.S. Military HIV Research Program (MHRP), Rockville, Maryland 20850
- Bill & Melinda Gates Foundation, Seattle, Washington 98102
| | - Francine E. McCutchan
- Division of Retrovirology, Walter Reed Army Institute of Research/U.S. Military HIV Research Program (MHRP), Rockville, Maryland 20850
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Larson BA, Fox MP, Rosen S, Bii M, Sigei C, Shaffer D, Sawe F, McCoy K, Wasunna M, Simon JL. Do the socioeconomic impacts of antiretroviral therapy vary by gender? A longitudinal study of Kenyan agricultural worker employment outcomes. BMC Public Health 2009; 9:240. [PMID: 19604381 PMCID: PMC2717954 DOI: 10.1186/1471-2458-9-240] [Citation(s) in RCA: 15] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Accepted: 07/15/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As access to antiretroviral therapy (ART) has grown in Africa, attention has turned to evaluating the socio-economic impacts of ART. One key issue is the extent to which improvements in health resulting from ART allows individuals to return to work and earn income. Improvements in health from ART may also be associated with reduced impaired presenteeism, which is the loss of productivity when an ill or disabled individual attends work but accomplishes less at his or her usual tasks or shifts to other, possibly less valuable, tasks. METHODS Longitudinal data for this analysis come from company payroll records for 97 HIV-infected tea estate workers (the index group, 56 women, 41 men) and a comparison group of all workers assigned to the same work teams (n = 2485, 1691 men, 794 women) for a 37-month period covering two years before and one year after initiating ART. We used nearest neighbour matching methods to estimate the impacts of HIV/AIDS and ART on three monthly employment outcomes for tea estate workers in Kenya--days plucking tea, days assigned to non-plucking assignments, and kilograms harvested when plucking. RESULTS The female index group worked 30% fewer days plucking tea monthly than the matched female comparison group during the final 9 months pre-ART. They also worked 87% more days on non-plucking assignments. While the monthly gap between the two groups narrowed after beginning ART, the female index group worked 30% fewer days plucking tea and about 100% more days on non-plucking tasks than the comparison group after one year on ART. The male index group was able to maintain a similar pattern of work as their comparison group except during the initial five months on therapy. CONCLUSION Significant impaired presenteeism continued to exist among the female index group after one year on ART. Future research needs to explore further the socio-economic implications of HIV-infected female workers on ART being less productive than the general female workforce over sustained periods of time.
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Affiliation(s)
- Bruce A Larson
- Department of International Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
- Center for International Health and Development, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
| | - Mathew P Fox
- Department of International Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
- Center for International Health and Development, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
| | - Sydney Rosen
- Department of International Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
- Center for International Health and Development, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
| | - Margret Bii
- Kenya Medical Research Institute, Hospital Road, BO Box 1357-20200, Kericho, Kenya
| | - Carolyne Sigei
- Kenya Medical Research Institute, Hospital Road, BO Box 1357-20200, Kericho, Kenya
| | - Douglas Shaffer
- United States Army Medical Research Unit-Kenya, Walter Reed Project, Hospital Road, BO Box 1357-20200, Kericho, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute, Hospital Road, BO Box 1357-20200, Kericho, Kenya
| | - Kelly McCoy
- Department of International Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
- Center for International Health and Development, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
| | - Monique Wasunna
- Kenya Medical Research Unit, P.O. Box 20778, 00200, Nairobi, Kenya
| | - Jonathan L Simon
- Department of International Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
- Center for International Health and Development, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 3rd Floor, Boston, MA 02118, USA
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Deborggraeve S, Laurent T, Espinosa D, Van der Auwera G, Mbuchi M, Wasunna M, El-Safi S, Al-Basheer AA, Arévalo J, Miranda-Verástegui C, Leclipteux T, Mertens P, Dujardin JC, Herdewijn P, Büscher P. A simplified and standardized polymerase chain reaction format for the diagnosis of leishmaniasis. J Infect Dis 2009; 198:1565-72. [PMID: 18816188 PMCID: PMC7109679 DOI: 10.1086/592509] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [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] [Indexed: 01/04/2023] Open
Abstract
Background. Definite diagnosis of Leishmania infections is based on demonstration of the parasite by microscopic analysis of tissue biopsy specimens or aspirate samples. However, microscopy generally shows low sensitivity and requires invasive sampling. Methods. We describe here the development of a simple and rapid test for the detection of polymerase chain reaction-amplified Leishmania DNA. A phase 1 evaluation of the text was conducted in clinical samples from 60 nonendemic and 45 endemic control subjects and from 44 patients with confirmed cutaneous leishmaniasis (CL), 12 with mucocutaneous leishmaniasis (MCL), and 43 with visceral leishmaniasis (VL) from Peru, Kenya, and Sudan. Results. The lower detection limits of the assay are 10 fg of Leishmania DNA and 1 parasite in 180 µL of blood. The specificity was 98.3% (95% confidence interval [CI], 91.1%–99.7%) and 95.6% (95% CI, 85.2%–98.8%) for nonendemic and endemic control samples, respectively, and the sensitivity was 93.2% (95% CI, 81.8%–97.7%), 91.7% (95% CI, 64.6%–98.5%), and 86% (95% CI, 72.7%–93.4%) for lesions from patients with CL or MCL and blood from patients with VL, respectively. Conclusions. The Leishmania OligoC-TesT showed high specificity and sensitivity in clinical samples and was able to detect the parasite in samples obtained by less invasive means, such as blood, lymph, and lesion scrapings. The assay is a promising new tool for simplified and standardized molecular detection of Leishmania parasites.
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Affiliation(s)
- Stijn Deborggraeve
- Department of Parasitology, Institute of Tropical Medicine Antwerp, Antwerp, Belgium.
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Boelaert M, El-Safi S, Hailu A, Mukhtar M, Rijal S, Sundar S, Wasunna M, Aseffa A, Mbui J, Menten J, Desjeux P, Peeling RW. Diagnostic tests for kala-azar: a multi-centre study of the freeze-dried DAT, rK39 strip test and KAtex in East Africa and the Indian subcontinent. Trans R Soc Trop Med Hyg 2007; 102:32-40. [PMID: 17942129 DOI: 10.1016/j.trstmh.2007.09.003] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 09/04/2007] [Accepted: 09/04/2007] [Indexed: 11/26/2022] Open
Abstract
Three diagnostic tests for visceral leishmaniasis (VL), the freeze-dried direct agglutination test (FD-DAT), the rK39 dipstick and a urine latex antigen test (KAtex), were evaluated for use in primary care in East Africa and the Indian subcontinent. Clinical suspects were prospectively recruited and tissue, blood and urine samples were taken. Direct microscopic examination of tissue smear, and FD-DAT, rK39 and KAtex were performed. Sensitivity and specificity with 95% credible intervals were estimated using Bayesian latent class analysis. On the Indian subcontinent both the FD-DAT and the rK39 strip test exceeded the 95% sensitivity and 90% specificity target, but not so in East Africa. Sensitivity of the FD-DAT was high in Ethiopia and Kenya but lower in Sudan, while its specificity was below 90% in Kenya. Sensitivity of the rK39 was below 80% in the three countries, and its specificity was only 70% in Ethiopia. KAtex showed moderate to very low sensitivity in all countries. FD-DAT and rK39 can be recommended for clinical practice on the Indian subcontinent. In East Africa, their clinical use should be carefully monitored. More work is needed to improve existing formats, and to develop better VL diagnostics.
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Affiliation(s)
- M Boelaert
- Epidemiology and Disease Control Unit, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.
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Sateren WB, Foglia G, Renzullo PO, Elson L, Wasunna M, Bautista CT, Birx DL. Epidemiology of HIV-1 Infection in Agricultural Plantation Residents in Kericho, Kenya. J Acquir Immune Defic Syndr 2006; 43:102-6. [PMID: 16885773 DOI: 10.1097/01.qai.0000226795.61957.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A cross-sectional study was performed to determine the prevalence and risk factors for HIV-1 infection among agricultural plantation residents in Kericho, Kenya. Volunteers were recruited, interviewed, and phlebotomized for HIV-1 serologic testing. Sex-specific adjusted odds ratios were estimated using logistic regression. The overall HIV-1 prevalence was 9.9% (81/820), with prevalence in women more than twice that in men (17.4% vs 8.0%, P=0.001). Among men, elevated HIV-1 prevalence was seen with increasing age, peaking in those older than 30 years (10.3%), marriage (10.4%), Luo tribe affiliation (23.5%), employment (8.9%), travel (11.0%), and being uncircumcised (29.2%). Among women, elevated HIV-1 prevalence was seen in those with no formal education (36.8%) and those who received goods in exchange for sex (36.0%). More than 97% of volunteers expressed a willingness to participate in future HIV-1 studies requiring semiannual visits. HIV prevention efforts have been implemented, along with further research to characterize this population for future cohort feasibility studies and HIV-1 vaccine efficacy trials.
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Affiliation(s)
- Warren B Sateren
- US Military HIV Research Program at the Walter Reed Army Institute of Research (WRAIR), Division of Retrovirology, and the Henry M. Jackson Foundation for the Advancement Military Medicine, Inc, Rockville, MD 20850, USA.
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Visawapoka U, Tovanabutra S, Currier JR, Cox JH, Mason CJ, Wasunna M, Ponglikitmongkol M, Dowling WE, Robb ML, Birx DL, McCutchan FE. Circulating and unique recombinant forms of HIV type 1 containing subsubtype A2. AIDS Res Hum Retroviruses 2006; 22:695-702. [PMID: 16831094 DOI: 10.1089/aid.2006.22.695] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-1 strains containing subsubtype A2 are relatively rare in the pandemic but have been repeatedly identified in Kenya, where candidate vaccines based in part on subtype A, but not A2 strains, may be evaluated. Among the most recent is CRF16_A2D, a circulating recombinant form (CRF) whose prototypes are complete or partial HIV-1 sequences from Kenya, Korea, and Argentina. Using samples from blood bank discards in Kenya and complete genome sequencing, this report further documents CRF16_A2D and related recombinants and identifies a second CRF, CRF21_A2D. The two A2-containing CRFs, and two recombinants related to CRF16_A2D, share common structural elements but appear to have been independently derived. Concerted selection may have influenced the emergence and spread of certain A2-containing strains in Kenya. The second complete subtype C sequence from Kenya is also reported here. Monitoring of A2-containing recombinants and subtype C strains, both relatively rare in Kenya, may be informative in the course of cohort development and evaluation of candidate vaccines.
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Affiliation(s)
- Unchalee Visawapoka
- Department of Biochemistry, Faculty of Science, Mahidol University, Bangkok, Thailand
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Abstract
Half a million new cases of visceral leishmaniasis occur each year, and 10% of these are fatal. New tools are urgently needed for mapping, diagnosing, and treating the disease.
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Affiliation(s)
- Asrat Hailu
- *To whom correspondence should be addressed. E-mail: (AH), E-mail: (CR)
| | | | - Catherine Royce
- *To whom correspondence should be addressed. E-mail: (AH), E-mail: (CR)
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Abstract
OBJECTIVES To estimate the impact of HIV/AIDS on individual labour productivity during disease progression. METHODS We used a retrospective cohort design to study the productivity and attendance of tea estate workers who died or were medically retired because of AIDS-related causes between 1997 and 2002 in western Kenya. We compared daily output in kilograms of tea leaves plucked, use of paid and unpaid leave and assignment to less strenuous tasks by 54 workers who died or were medically retired because of AIDS to those of comparison workers, matched on time and tea field using longitudinal regression. RESULTS HIV-positive workers plucked less tea in the 18 months preceding AIDS-related termination and used more leave in the 3 years before termination. After adjusting for age and environmental factors, cases plucked between 4.11 and 7.93 kg/day less in the last year and a half before termination. Cases used between 9.2 and 11.0 more sick leave days, between 6.4 and 8.3 more annual leave days, between 19.9 and 11.8 more casual leave days, and spent between 19.2 and 21.8 more days doing less strenuous tasks in the 2 years before termination than did comparison pluckers. Tea pluckers who terminated because of AIDS-related causes earned 16.0% less in their second year before termination and 17.7% less in the year before termination. CONCLUSION These results provide empirical estimates of the impact of HIV/AIDS on labour productivity. As workers often bring unrecorded 'helpers', actual differences may be greater. Decreased attendance and output may put sick workers in jeopardy of losing their jobs and impose financial burdens on employers.
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Affiliation(s)
- Matthew P Fox
- Center for International Health and Development, Boston University School of Public Health, Boston, MA 02118, USA.
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Mbui J, Rashid R, Lodenyo H, Nyakundi P, Kipmutai R, Mutuma G, Kirigi G, Kinoti D, Wasunna M. Visceral leishmaniasis with concomittant post kala-azar dermal leishmaniasis responds to oral sitamaquine: case report. ACTA ACUST UNITED AC 2003; 80:440-2. [PMID: 14601788 DOI: 10.4314/eamj.v80i8.8738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a rare case of visceral leishmanisis with concomitant post kala-azar dermal leishmaniasis as the initial presentation in a female patient from Baringo district, Rift valley province, Kenya.
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Affiliation(s)
- J Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, P.O. Box 54840, Nairobi, Kenya
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Mbui J, Wasunna M, Martin K. A simple and inexpensive medium for culture of splenic aspirates in visceral leishmaniasis. East Afr Med J 1999; 76:358. [PMID: 10750528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Njenga S, Mitsui Y, Muita M, Fujimaki Y, Mbugua J, Kirigi G, Gachihi G, Wasunna M, Aoki Y. The effect of sodium bicarbonate on a single dose of diethylcarbamazine therapy in patients with bancroftian filariasis in Kenya. Parasitol Int 1997. [DOI: 10.1016/s1383-5769(97)00026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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