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Ding X, Wang L, Msellem MI, Hu Y, Qiu J, Liu S, Zhang M, Zhu L, Latour JM. Evaluation of a Neonatal Resuscitation Training Programme for Healthcare Professionals in Zanzibar, Tanzania: A Pre-post Intervention Study. Front Pediatr 2021; 9:693583. [PMID: 34262890 PMCID: PMC8273261 DOI: 10.3389/fped.2021.693583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Neonatal mortality rates remain high in Sub-Saharan African countries. Improving the newborn resuscitation skills of healthcare professionals is important in addressing this challenge. The aim of this study was to evaluate a neonatal resuscitation training programme delivered over a two-year period for healthcare professionals in Zanzibar, Tanzania. Methods: A pre- and post-intervention study was designed. We delivered neonatal resuscitation training over a 2-day period in 2017 and 2 days of refresher training in 2018. Knowledge was evaluated by a self-designed survey (11 items with a total score of 22) before and after the two training periods, and skills were evaluated by a skills checklist (six domains with 25 items with a total score of 50) completed by the trainers based on their observations. Statistical analysis included differences in the knowledge and skills scores before and after the training sessions and between the two periods. Results: A total of 23 healthcare professionals participated and completed both neonatal resuscitation training sessions. The knowledge mean scores before and after the training in 2017 increased from 9.60 to 13.60 (95% CI: -5.900; -2.099, p < 0.001), and in 2018, the scores increased from 10.80 to 15.44 (95% CI: -6.062; -3.217, p < 0.001). The mean knowledge scores post-training over time were 13.60 in 2017 and 15.44 in 2018 (95% CI: -3.489; 0.190, p = 0.030). The resuscitation skills performance between the two time periods increased from a mean of 32.26 (SD = 2.35) to a mean of 42.43 (SD = 1.73) (95% CI: -11.402; -8.945, p < 0.001). Conclusion: The neonatal resuscitation training programme increased the theoretical knowledge and resuscitation skills before and after the two training sessions and over time after a 9-month period. Continuous neonatal resuscitation training based on the local needs in resource-limited countries is essential to provide confidence in healthcare professionals to initiate resuscitation and to improve newborn outcomes.
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Affiliation(s)
- Xiang Ding
- International Affairs, Hunan Children's Hospital, Changsha, China
| | - Li Wang
- International Affairs, Hunan Children's Hospital, Changsha, China
| | | | - Yaojia Hu
- Nursing School, Hunan University of Chinese Medicine, Changsha, China
| | - Jun Qiu
- Editing Office, Journal of Clinical Pediatric Surgery, Hunan Children's Hospital, Changsha, China
| | - Shiying Liu
- International Affairs, Hunan Children's Hospital, Changsha, China
| | - Mi Zhang
- Neonatal Department, Hunan Children's Hospital, Changsha, China
| | - Lihui Zhu
- International Affairs, Hunan Children's Hospital, Changsha, China.,Nursing Department, Hunan Children's Hospital, Changsha, China
| | - Jos M Latour
- International Affairs, Hunan Children's Hospital, Changsha, China.,Faculty of Health, University of Plymouth, Plymouth, United Kingdom
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Ashton RA, Bennett A, Al-Mafazy AW, Abass AK, Msellem MI, McElroy P, Kachur SP, Ali AS, Yukich J, Eisele TP, Bhattarai A. Use of Routine Health Information System Data to Evaluate Impact of Malaria Control Interventions in Zanzibar, Tanzania from 2000 to 2015. EClinicalMedicine 2019; 12:11-19. [PMID: 31388659 PMCID: PMC6677660 DOI: 10.1016/j.eclinm.2019.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 03/27/2019] [Accepted: 05/28/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Impact evaluations allow countries to assess public health gains achieved through malaria investments. This study uses routine health management information system (HMIS) data from Zanzibar to describe changes in confirmed malaria incidence and impact of case management and vector control interventions during 2000-2015. METHODS HMIS data from 129 (82%) public outpatient facilities were analyzed using interrupted time series models to estimate the impact of artemisinin-based combination therapy (ACT), indoor residual spray, and long-lasting insecticidal nets. Evaluation periods were defined as pre-intervention (January 2000 to August 2003), ACT-only (September 2003 to December 2005) and ACT plus vector control (2006-2015). FINDINGS After accounting for climate, seasonality, diagnostic testing rates, and outpatient attendance, average monthly incidence of confirmed malaria showed no trend over the pre-intervention period 2000-2003 (incidence rate ratio (IRR) 0.998, 95% CI 0.995-1.000). During the ACT-only period (2003-2005), the average monthly malaria incidence rate declined compared to the pre-intervention period, showing an overall declining trend during the ACT-only period (IRR 0.984, 95% CI 0.978-0.990). There was no intercept change at the start of the ACT-only period (IRR 1.081, 95% CI 0.968-1.208), but a drop in intercept was identified at the start of the ACT plus vector control period (IRR 0.683, 95% CI 0.597-0.780). During the ACT plus vector control period (2006-2015), the rate of decline in average monthly malaria incidence slowed compared to the ACT-only period, but the incidence rate continued to show an overall slight declining trend during 2006-2015 (IRR 0.993, 95% CI 0.992-0.994). INTERPRETATION This study presents a rigorous approach to the use of HMIS data in evaluating the impact of malaria control interventions. Evidence is presented for a rapid decline in malaria incidence during the period of ACT roll out compared to pre-intervention, with a rapid drop in malaria incidence following introduction of vector control and a slower declining incidence trend thereafter.
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Affiliation(s)
- Ruth A. Ashton
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
- Corresponding author at: School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2300, New Orleans, LA, USA.
| | - Adam Bennett
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
- Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, CA, USA
| | - Abdul-Wahid Al-Mafazy
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, United Republic of Tanzania
| | - Ali K. Abass
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, United Republic of Tanzania
| | | | - Peter McElroy
- U.S. President's Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - S. Patrick Kachur
- Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Mailman School of Public Health, Columbia University, NY, New York, USA
| | - Abdullah S. Ali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, United Republic of Tanzania
| | - Joshua Yukich
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Thomas P. Eisele
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Achuyt Bhattarai
- U.S. President's Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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3
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Morris U, Msellem MI, Mkali H, Islam A, Aydin-Schmidt B, Jovel I, Shija SJ, Khamis M, Ali SM, Hodzic L, Magnusson E, Poirot E, Bennett A, Sachs MC, Tarning J, Mårtensson A, Ali AS, Björkman A. A cluster randomised controlled trial of two rounds of mass drug administration in Zanzibar, a malaria pre-elimination setting-high coverage and safety, but no significant impact on transmission. BMC Med 2018; 16:215. [PMID: 30526588 PMCID: PMC6287359 DOI: 10.1186/s12916-018-1202-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/29/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Mass drug administration (MDA) has the potential to interrupt malaria transmission and has been suggested as a tool for malaria elimination in low-endemic settings. This study aimed to determine the effectiveness and safety of two rounds of MDA in Zanzibar, a pre-elimination setting. METHODS A cluster randomised controlled trial was conducted in 16 areas considered as malaria hotspots, with an annual parasite index of > 0.8%. The areas were randomised to eight intervention and eight control clusters. The intervention included two rounds of MDA with dihydroartemisinin-piperaquine and single low-dose primaquine 4 weeks apart in May-June 2016. Primary and secondary outcomes were cumulative confirmed malaria case incidences 6 months post-MDA and parasite prevalences determined by PCR 3 months post-MDA. Additional outcomes included intervention coverage, treatment adherence, occurrence of adverse events, and cumulative incidences 3, 12, and 16 months post-MDA. RESULTS Intervention coverage was 91.0% (9959/10944) and 87.7% (9355/10666) in the first and second rounds, respectively; self-reported adherence was 82.0% (881/1136) and 93.7% (985/1196). Adverse events were reported in 11.6% (147/1268) and 3.2% (37/1143) of post-MDA survey respondents after both rounds respectively. No serious adverse event was reported. No difference in cumulative malaria case incidence was observed between the control and intervention arms 6 months post-MDA (4.2 and 3.9 per 1000 population; p = 0.94). Neither was there a difference in PCR-determined parasite prevalences 3 months post-MDA (1.4% and 1.7%; OR = 1.0, p = 0.94), although having received at least the first MDA was associated with reduced odds of malaria infection (aOR = 0.35; p = 0.02). Among confirmed malaria cases at health facilities, 26.0% and 26.3% reported recent travel outside Zanzibar in the intervention and control shehias (aOR ≥ 85; p ≤ 0.001). CONCLUSIONS MDA was implemented with high coverage, adherence, and tolerability. Despite this, no significant impact on transmission was observed. The findings suggest that two rounds of MDA in a single year may not be sufficient for a sustained impact on transmission in a pre-elimination setting, especially when the MDA impact is restricted by imported malaria. Importantly, this study adds to the limited evidence for the use of MDA in low transmission settings in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov, NCT02721186 (registration date: March 29, 2016).
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Affiliation(s)
- Ulrika Morris
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Mwinyi I. Msellem
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Humphrey Mkali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Atiqul Islam
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Berit Aydin-Schmidt
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Irina Jovel
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Shija Joseph Shija
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Mwinyi Khamis
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Safia Mohammed Ali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Lamija Hodzic
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Ellinor Magnusson
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Eugenie Poirot
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
| | - Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
| | - Michael C. Sachs
- Biostatistics Unit, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joel Tarning
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Andreas Mårtensson
- Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Abdullah S. Ali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Anders Björkman
- Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden
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4
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Andersson M, Kabayiza JC, Elfving K, Nilsson S, Msellem MI, Mårtensson A, Björkman A, Bergström T, Lindh M. Coinfection with Enteric Pathogens in East African Children with Acute Gastroenteritis-Associations and Interpretations. Am J Trop Med Hyg 2018; 98:1566-1570. [PMID: 29692296 DOI: 10.4269/ajtmh.17-0473] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Enteric coinfections among children in low-income countries are very common, but it is not well known if specific pathogen combinations are associated or have clinical importance. In this analysis, feces samples from children in Rwanda and Zanzibar less than 5 years of age, with (N = 994) or without (N = 324) acute diarrhea, were analyzed by real-time polymerase chain reaction targeting a wide range of pathogens. Associations were investigated by comparing co-detection and mono-detection frequencies for all pairwise pathogen combinations. More than one pathogen was detected in 840 samples (65%). A negative association (coinfections being less common than expected from probability) was observed for rotavirus in combination with Shigella, Campylobacter, or norovirus genogroup II, but only in patients, which is statistically expected for agents that independently cause diarrhea. A positive correlation was observed, in both patients and controls, between Ct (threshold cycle) values for certain virulence factor genes in enteropathogenic Escherichia coli (EPEC) (eae and bfpA) and toxin genes in enterotoxigenic E. coli (eltB and estA), allowing estimation of how often these genes were present in the same bacteria. A significant positive association in patients only was observed for Shigella and EPEC-eae, suggesting that this coinfection might interact in a manner that enhances symptoms. Although interaction between pathogens that affect symptoms is rare, this work emphasizes the importance and difference in interpretation of coinfections depending on whether they are positively or negatively associated.
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Affiliation(s)
- Maria Andersson
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | | | - Kristina Elfving
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | | | - Mwinyi I Msellem
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Andreas Mårtensson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Anders Björkman
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Bergström
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Lindh
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
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5
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Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Björkman A, Burchett HED, Clarke SE, Cundill B, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Mangham-Jefferies L, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Rowland MW, Shakely D, Staedke SG, Vestergaard LS, Webster J, Whitty CJM, Wiseman VL, Yeung S, Schellenberg D, Hopkins H. The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium. Am J Trop Med Hyg 2017; 97:1170-1179. [PMID: 28820705 PMCID: PMC5637593 DOI: 10.4269/ajtmh.16-0955] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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] [Indexed: 01/21/2023] Open
Abstract
Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.
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Affiliation(s)
- Katia J Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Baptiste Leurent
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- University of Copenhagen, Copenhagen, Denmark.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sham Lal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Toby Leslie
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Department for Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Makerere University School of Public Health, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Mark W Rowland
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden.,Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sarah G Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Virginia L Wiseman
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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6
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Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CIR, Leurent B, Ansah EK, Baiden F, Baltzell KA, Björkman A, Burchett HED, Clarke SE, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Jefferies LM, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Reyburn H, Rowland MW, Shakely D, Vestergaard LS, Webster J, Wiseman VL, Yeung S, Schellenberg D, Staedke SG, Whitty CJM. Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ 2017; 356:j1054. [PMID: 28356302 PMCID: PMC5370398 DOI: 10.1136/bmj.j1054] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.
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Affiliation(s)
- Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Matthew E Cairns
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Baptiste Leurent
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | - Kristian S Hansen
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- University of Copenhagen, Copenhagen, DK1014, Denmark
| | | | - Sham Lal
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Toby Leslie
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mark W Rowland
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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7
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Aydin-Schmidt B, Morris U, Ding XC, Jovel I, Msellem MI, Bergman D, Islam A, Ali AS, Polley S, Gonzalez IJ, Mårtensson A, Björkman A. Field Evaluation of a High Throughput Loop Mediated Isothermal Amplification Test for the Detection of Asymptomatic Plasmodium Infections in Zanzibar. PLoS One 2017; 12:e0169037. [PMID: 28095434 PMCID: PMC5240913 DOI: 10.1371/journal.pone.0169037] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 09/19/2016] [Accepted: 12/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND New field applicable diagnostic tools are needed for highly sensitive detection of residual malaria infections in pre-elimination settings. Field performance of a high throughput DNA extraction system for loop mediated isothermal amplification (HTP-LAMP) was therefore evaluated for detecting malaria parasites among asymptomatic individuals in Zanzibar. METHODS HTP-LAMP performance was evaluated against real-time PCR on 3008 paired blood samples collected on filter papers in a community-based survey in 2015. RESULTS The PCR and HTP-LAMP determined malaria prevalences were 1.6% (95%CI 1.3-2.4) and 0.7% (95%CI 0.4-1.1), respectively. The sensitivity of HTP-LAMP compared to PCR was 40.8% (CI95% 27.0-55.8) and the specificity was 99.9% (CI95% 99.8-100). For the PCR positive samples, there was no statistically significant difference between the geometric mean parasite densities among the HTP-LAMP positive (2.5 p/μL, range 0.2-770) and HTP-LAMP negative (1.4 p/μL, range 0.1-7) samples (p = 0.088). Two lab technicians analysed up to 282 samples per day and the HTP-LAMP method was experienced as user friendly. CONCLUSIONS Although field applicable, this high throughput format of LAMP as used here was not sensitive enough to be recommended for detection of asymptomatic low-density infections in areas like Zanzibar, approaching malaria elimination.
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Affiliation(s)
- Berit Aydin-Schmidt
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Unit of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Morris
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Xavier C Ding
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Irina Jovel
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Mwinyi I Msellem
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Daniel Bergman
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Atiqul Islam
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Abdullah S Ali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Spencer Polley
- Department of Clinical Parasitology, Hospital for Tropical Diseases, University College London Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Iveth J Gonzalez
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Andreas Mårtensson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Anders Björkman
- Centre for Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
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Elfving K, Shakely D, Andersson M, Baltzell K, Ali AS, Bachelard M, Falk KI, Ljung A, Msellem MI, Omar RS, Parola P, Xu W, Petzold M, Trollfors B, Björkman A, Lindh M, Mårtensson A. Acute Uncomplicated Febrile Illness in Children Aged 2-59 months in Zanzibar - Aetiologies, Antibiotic Treatment and Outcome. PLoS One 2016; 11:e0146054. [PMID: 26821179 PMCID: PMC4731140 DOI: 10.1371/journal.pone.0146054] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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: 09/02/2015] [Accepted: 12/11/2015] [Indexed: 12/29/2022] Open
Abstract
Background Despite the fact that a large proportion of children with fever in Africa present at primary health care facilities, few studies have been designed to specifically study the causes of uncomplicated childhood febrile illness at this level of care, especially in areas like Zanzibar that has recently undergone a dramatic change from high to low malaria transmission. Methods We prospectively studied the aetiology of febrile illness in 677 children aged 2–59 months with acute uncomplicated fever managed by IMCI (Integrated Management of Childhood Illness) guidelines in Zanzibar, using point-of-care tests, urine culture, blood-PCR, chest X-ray (CXR) of IMCI-pneumonia classified patients, and multiple quantitative (q)PCR investigations of nasopharyngeal (NPH) (all patients) and rectal (GE) swabs (diarrhoea patients). For comparison, we also performed NPH and GE qPCR analyses in 167 healthy community controls. Final fever diagnoses were retrospectively established based on all clinical and laboratory data. Clinical outcome was assessed during a 14-day follow-up. The utility of IMCI for identifying infections presumed to require antibiotics was evaluated. Findings NPH-qPCR and GE-qPCR detected ≥1 pathogen in 657/672 (98%) and 153/164 (93%) of patients and 158/166 (95%) and 144/165 (87%) of controls, respectively. Overall, 57% (387/677) had IMCI-pneumonia, but only 12% (42/342) had CXR-confirmed pneumonia. Two patients were positive for Plasmodium falciparum. Respiratory syncytial virus (24.5%), influenza A/B (22.3%), rhinovirus (10.5%) and group-A streptococci (6.4%), CXR-confirmed pneumonia (6.2%), Shigella (4.3%) were the most common viral and bacterial fever diagnoses, respectively. Blood-PCR conducted in a sub-group of patients (n = 83) without defined fever diagnosis was negative for rickettsiae, chikungunya, dengue, Rift Valley fever and West Nile viruses. Antibiotics were prescribed to 500 (74%) patients, but only 152 (22%) had an infection retrospectively considered to require antibiotics. Clinical outcome was generally good. However, two children died. Only 68 (11%) patients remained febrile on day 3 and three of them had verified fever on day 14. An additional 29 (4.5%) children had fever relapse on day 14. Regression analysis determined C-reactive Protein (CRP) as the only independent variable significantly associated with CXR-confirmed pneumonia. Conclusions This is the first study on uncomplicated febrile illness in African children that both applied a comprehensive laboratory panel and a healthy control group. A majority of patients had viral respiratory tract infection. Pathogens were frequently detected by qPCR also in asymptomatic children, demonstrating the importance of incorporating controls in fever aetiology studies. The precision of IMCI for identifying infections requiring antibiotics was low.
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Affiliation(s)
- Kristina Elfving
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
- Department of Paediatrics, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Deler Shakely
- Malaria Research, Department of Microbiology, Tumour and Cell biology, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Kungälv, Sweden
| | - Maria Andersson
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, United States of America
| | - Abdullah S. Ali
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Marc Bachelard
- Department of Paediatrics, University of Gothenburg, Gothenburg, Sweden
| | - Kerstin I. Falk
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Stockholm, Sweden
| | - Annika Ljung
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | - Mwinyi I. Msellem
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Rahila S. Omar
- Zanzibar Malaria Elimination Programme, Ministry of Health, Zanzibar, Tanzania
| | - Philippe Parola
- Aix Marseille University, UM63, WHO collaborative centre for rickettsioses and other arthropod borne bacterial diseases, Faculté de Médecine, Marseille, France
| | - Weiping Xu
- Malaria Research, Department of Microbiology, Tumour and Cell biology, Karolinska Institutet, Stockholm, Sweden
| | - Max Petzold
- Akademistatistik, Centre for Applied Biostatistics, Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Birger Trollfors
- Department of Paediatrics, University of Gothenburg, Gothenburg, Sweden
| | - Anders Björkman
- Malaria Research, Department of Microbiology, Tumour and Cell biology, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Lindh
- Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Mårtensson
- Malaria Research, Department of Microbiology, Tumour and Cell biology, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
- Department of Women’s and Children’s Health, International Maternal and Child Health Unit (IMCH), Uppsala University, Uppsala, Sweden
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Morris U, Xu W, Msellem MI, Schwartz A, Abass A, Shakely D, Cook J, Bhattarai A, Petzold M, Greenhouse B, Ali AS, Björkman A, Fröberg G, Mårtensson A. Characterising temporal trends in asymptomatic Plasmodium infections and transporter polymorphisms during transition from high to low transmission in Zanzibar, 2005-2013. Infect Genet Evol 2015; 33:110-7. [PMID: 25917493 PMCID: PMC10445533 DOI: 10.1016/j.meegid.2015.04.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/14/2015] [Accepted: 04/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Improved understanding of the asymptomatic malaria parasite reservoir is a prerequisite to pursue malaria elimination efforts. We therefore characterised temporal trends and transporter polymorphisms in asymptomatic Plasmodium infections during the transition from high to low transmission in Zanzibar. METHODS Healthy individuals participating in cross-sectional surveys conducted 2005-2013 were screened for asymptomatic malaria by PCR. Complexity/diversity of infection and transporter polymorphisms were assessed in Plasmodium falciparum positive samples. Symptomatic samples were included for comparison of polymorphisms in 2013. RESULTS PCR-determined parasite prevalence declined from 21.1% (CI95% 17.4-24.9) to 2.3% (CI95% 1.7-2.9) from 2005 to 2013. P. falciparum remained the predominant species; prevalence was highest in children and young adults aged 5-25 years. Parasite densities and complexity of infection, but not population genetic diversity of P. falciparum, decreased from 2005-2009. pfcrt 76T (99.2-64.7%, p < 0.001) and pfmdr1 86Y frequencies (89.4-66.7%, p = 0.03) decreased over time. Pfmdr1 (a.a.86,184,1246) YYY and YYD haplotypes were more frequent in asymptomatic than symptomatic infections in 2013 (p < 0.001). CONCLUSIONS There is a declining, albeit persistent, reservoir of parasites present at low-densities in asymptomatic individuals in Zanzibar. This study revealed important characteristics of the remaining parasite population, including intriguing temporal trends in molecular markers associated with antimalarial resistance, which need to be further investigated.
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Affiliation(s)
- Ulrika Morris
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.
| | - Weiping Xu
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Mwinyi I Msellem
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Alanna Schwartz
- Department of Medicine, University of California San Francisco, CA, USA
| | - Ali Abass
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Delér Shakely
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Kungälv Hospital, Kungälv, Sweden
| | - Jackie Cook
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Achuyt Bhattarai
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Max Petzold
- Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bryan Greenhouse
- Department of Medicine, University of California San Francisco, CA, USA
| | - Abdullah S Ali
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Anders Björkman
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Gabrielle Fröberg
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Mårtensson
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Sweden
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10
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Morris U, Khamis M, Aydin-Schmidt B, Abass AK, Msellem MI, Nassor MH, González IJ, Mårtensson A, Ali AS, Björkman A, Cook J. Field deployment of loop-mediated isothermal amplification for centralized mass-screening of asymptomatic malaria in Zanzibar: a pre-elimination setting. Malar J 2015; 14:205. [PMID: 25982190 PMCID: PMC4440539 DOI: 10.1186/s12936-015-0731-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 03/23/2015] [Accepted: 05/08/2015] [Indexed: 12/14/2022] Open
Abstract
Background Molecular tools for detection of low-density asymptomatic Plasmodium infections are needed in malaria elimination efforts. This study reports results from the hitherto largest implementation of loop-mediated isothermal amplification (LAMP) for centralized mass screening of asymptomatic malaria in Zanzibar. Methods Healthy individuals present and willing to participate in randomly selected households in 60 villages throughout Zanzibar were screened for malaria by rapid diagnostic tests (RDT). In 50 % of the study households, participants were asked to provide 60 μL of finger-prick blood for additional LAMP screening. LAMP was conducted in two centralized laboratories in Zanzibar, by trained technicians with limited or no previous experience of molecular methods. The LAMP assay was performed with LoopampTM MALARIA Pan/Pf Detection Kit (Eiken Chemical Company, Japan). Samples positive for Plasmodium genus (Pan)-LAMP were re-tested using Plasmodium falciparum-specific LAMP kits. Results Paired RDT and LAMP samples were available from 3983 individuals. The prevalence of asymptomatic malaria was 0.5 % (CI 95 % 0.1-0.8) and 1.6 % (CI 95 % 1.1-2.2) by RDT and Pan-LAMP, respectively. LAMP detected 3.4 (CI 95 % 2.2-5.2) times more Plasmodium positive samples than RDT. DNA contamination was experienced, but solved by repetitive decontamination of all equipment and reagents. Conclusions LAMP is a simple and sensitive molecular tool, and has potential in active surveillance and mass-screening programmes for detection of low-density asymptomatic malaria in pre-elimination settings. However, in order to deploy LAMP more effectively in field settings, protocols may need to be adapted for processing larger numbers of samples. A higher throughput, affordable closed system would be ideal to avoid contamination. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0731-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulrika Morris
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77, Stockholm, Sweden.
| | - Mwinyi Khamis
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania.
| | - Berit Aydin-Schmidt
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77, Stockholm, Sweden.
| | - Ali K Abass
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania
| | - Mwinyi I Msellem
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania.
| | - Majda H Nassor
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania.
| | - Iveth J González
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland.
| | - Andreas Mårtensson
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
| | - Abdullah S Ali
- Zanzibar Malaria Elimination Programme (ZAMEP), Ministry of Health, Zanzibar, Tanzania.
| | - Anders Björkman
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77, Stockholm, Sweden.
| | - Jackie Cook
- Malaria Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77, Stockholm, Sweden. .,London School of Hygiene and Tropical Medicine, London, UK.
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11
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Aydin-Schmidt B, Xu W, González IJ, Polley SD, Bell D, Shakely D, Msellem MI, Björkman A, Mårtensson A. Loop mediated isothermal amplification (LAMP) accurately detects malaria DNA from filter paper blood samples of low density parasitaemias. PLoS One 2014; 9:e103905. [PMID: 25105591 PMCID: PMC4126669 DOI: 10.1371/journal.pone.0103905] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/03/2014] [Indexed: 11/18/2022] Open
Abstract
Background Loop mediated isothermal amplification (LAMP) provides an opportunity for improved, field-friendly detection of malaria infections in endemic areas. However data on the diagnostic accuracy of LAMP for active case detection, particularly low-density parasitaemias, are lacking. We therefore evaluated the performance of a new LAMP kit compared with PCR using DNA from filter paper blood spots. Methods and Findings Samples from 865 fever patients and 465 asymptomatic individuals collected in Zanzibar were analysed for Pan (all species) and Pf (P. falciparum) DNA with the Loopamp MALARIA Pan/Pf kit. Samples were amplified at 65°C for 40 minutes in a real-time turbidimeter and results were compared with nested PCR. Samples with discordant results between LAMP and nested PCR were analysed with real-time PCR. The real-time PCR corrected nested PCR result was defined as gold standard. Among the 117 (13.5%) PCR detected P. falciparum infections from fever patients (mean parasite density 7491/µL, range 6–782,400) 115, 115 and 111 were positive by Pan-LAMP, Pf-LAMP and nested PCR, respectively. The sensitivities were 98.3% (95%CI 94–99.8) for both Pan and Pf-LAMP. Among the 54 (11.6%) PCR positive samples from asymptomatic individuals (mean parasite density 10/µL, range 0–4972) Pf-LAMP had a sensitivity of 92.7% (95%CI 80.1–98.5) for detection of the 41 P. falciparum infections. Pan-LAMP had sensitivities of 97% (95%CI 84.2–99.9) and 76.9% (95%CI 46.2–95) for detection of P. falciparum and P. malariae, respectively. The specificities for both Pan and Pf-LAMP were 100% (95%CI 99.1–100) in both study groups. Conclusion Both components of the Loopamp MALARIA Pan/Pf detection kit revealed high diagnostic accuracy for parasite detection among fever patients and importantly also among asymptomatic individuals of low parasite densities from minute blood volumes preserved on filter paper. These data support LAMPs potential role for improved detection of low-density malaria infections in pre-elimination settings.
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Affiliation(s)
- Berit Aydin-Schmidt
- Malaria Research, Department of Microbiology, Tumor and Cellbiology, Karolinska Institutet, Stockholm, Sweden
- Unit of infectious diseases, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Weiping Xu
- Malaria Research, Department of Microbiology, Tumor and Cellbiology, Karolinska Institutet, Stockholm, Sweden
| | - Iveth J. González
- Department of Clinical Parasitology, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Spencer D. Polley
- Hospital for Tropical Diseases, University College London Hospitals, London, United Kingdom
- NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College, London, United Kingdom
| | - David Bell
- Global Good Fund, Bellevue, Washington, United States of America
| | - Delér Shakely
- Malaria Research, Department of Microbiology, Tumor and Cellbiology, Karolinska Institutet, Stockholm, Sweden
| | - Mwinyi I. Msellem
- Zanzibar Malaria Elimination Program, Ministry of Health, Zanzibar, Tanzania
| | - Anders Björkman
- Malaria Research, Department of Microbiology, Tumor and Cellbiology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Mårtensson
- Malaria Research, Department of Microbiology, Tumor and Cellbiology, Karolinska Institutet, Stockholm, Sweden
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Center for Clinical Research, Sörmland County Council, Sörmland, Sweden
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Plotkin M, Said K, Msellem MI, Chase RP, Hendler N, Khamis AR, Roman E, Kitojo C, Schwartz AC, Gutman J, McElroy PD. Placental malaria is rare among Zanzibari pregnant women who did not receive intermittent preventive treatment in pregnancy. Am J Trop Med Hyg 2014; 91:367-373. [PMID: 24891469 PMCID: PMC4125264 DOI: 10.4269/ajtmh.13-0586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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] [Indexed: 11/26/2022] Open
Abstract
Zanzibar has transitioned from malaria control to the pre-elimination phase, and the continued need for intermittent preventive treatment during pregnancy (IPTp) has been questioned. We conducted a prospective observational study to estimate placental malaria positivity rate among women who did not receive IPTp with sulfadoxine-pyrimethamine. A convenience sample of pregnant women was enrolled from six clinics on the day of delivery from August of 2011 to September of 2012. Dried placental blood spot specimens were analyzed by polymerase chain reaction (PCR); 9 of 1,349 specimens (0.7%; precision estimate = 0.2–1.1%) were PCR-positive for Plasmodium falciparum. Placental infection was detected on both Pemba (N = 3) and Unguja (N = 6). Placental malaria positivity in Zanzibar was low, even in the absence of IPTp. It may be reasonable for the Ministry of Health to consider discontinuing IPTp, intensifying surveillance efforts, and promoting insecticide-treated nets and effective case management of malaria in pregnancy.
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Affiliation(s)
- Marya Plotkin
- *Address correspondence to Marya Plotkin, PO Box 9170, Dar es Salaam, Tanzania. E-mail:
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Shakely D, Elfving K, Aydin-Schmidt B, Msellem MI, Morris U, Omar R, Weiping X, Petzold M, Greenhouse B, Baltzell KA, Ali AS, Björkman A, Mårtensson A. The usefulness of rapid diagnostic tests in the new context of low malaria transmission in Zanzibar. PLoS One 2013; 8:e72912. [PMID: 24023791 PMCID: PMC3762850 DOI: 10.1371/journal.pone.0072912] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [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: 04/23/2013] [Accepted: 07/12/2013] [Indexed: 11/19/2022] Open
Abstract
Background We assessed if histidine-rich-protein-2 (HRP2) based rapid diagnostic test (RDT) remains an efficient tool for Plasmodium falciparum case detection among fever patients in Zanzibar and if primary health care workers continue to adhere to RDT results in the new epidemiological context of low malaria transmission. Further, we evaluated the performance of RDT within the newly adopted integrated management of childhood illness (IMCI) algorithm in Zanzibar. Methods and Findings We enrolled 3890 patients aged ≥2 months with uncomplicated febrile illness in this health facility based observational study conducted in 12 primary health care facilities in Zanzibar, between May-July 2010. One patient had an inconclusive RDT result. Overall 121/3889 (3.1%) patients were RDT positive. The highest RDT positivity rate, 32/528 (6.1%), was found in children aged 5–14 years. RDT sensitivity and specificity against PCR was 76.5% (95% CI 69.0–83.9%) and 99.9% (95% CI 99.7–100%), and against blood smear microscopy 78.6% (95% CI 70.8–85.1%) and 99.7% (95% CI 99.6–99.9%), respectively. All RDT positive, but only 3/3768 RDT negative patients received anti-malarial treatment. Adherence to RDT results was thus 3887/3889 (99.9%). RDT performed well in the IMCI algorithm with equally high adherence among children <5 years as compared with other age groups. Conclusions The sensitivity of HRP-2 based RDT in the hands of health care workers compared with both PCR and microscopy for P. falciparum case detection was relatively low, whereas adherence to test results with anti-malarial treatment was excellent. Moreover, the results provide evidence that RDT can be reliably integrated in IMCI as a tool for improved childhood fever management. However, the relatively low RDT sensitivity highlights the need for improved quality control of RDT use in primary health care facilities, but also for more sensitive point-of-care malaria diagnostic tools in the new epidemiological context of low malaria transmission in Zanzibar. Trial registration ClinicalTrials.gov NCT01002066
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Affiliation(s)
- Delér Shakely
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Kungälv, Sweden
- * E-mail:
| | - Kristina Elfving
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Berit Aydin-Schmidt
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mwinyi I. Msellem
- Zanzibar Malaria Control Programme, Ministry of Health, Zanzibar, Tanzania
| | - Ulrika Morris
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Rahila Omar
- Zanzibar Malaria Control Programme, Ministry of Health, Zanzibar, Tanzania
| | - Xu Weiping
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Max Petzold
- Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bryan Greenhouse
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Kimberly A. Baltzell
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, California, United States of America
| | - Abdullah S. Ali
- Zanzibar Malaria Control Programme, Ministry of Health, Zanzibar, Tanzania
| | - Anders Björkman
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Mårtensson
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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14
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Morris U, Aydin-Schmidt B, Shakely D, Mårtensson A, Jörnhagen L, Ali AS, Msellem MI, Petzold M, Gil JP, Ferreira PE, Björkman A. Rapid diagnostic tests for molecular surveillance of Plasmodium falciparum malaria -assessment of DNA extraction methods and field applicability. Malar J 2013; 12:106. [PMID: 23510231 PMCID: PMC3605315 DOI: 10.1186/1475-2875-12-106] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [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: 12/21/2012] [Accepted: 03/10/2013] [Indexed: 11/20/2022] Open
Abstract
Background The need for new malaria surveillance tools and strategies is critical, given improved global malaria control and regional elimination efforts. High quality Plasmodium falciparum DNA can reliably be extracted from malaria rapid diagnostic tests (RDTs). Together with highly sensitive molecular assays, wide scale collection of used RDTs may serve as a modern tool for improved malaria case detection and drug resistance surveillance. However, comparative studies of DNA extraction efficiency from RDTs and the field applicability are lacking. The aim of this study was to compare and evaluate different methods of DNA extraction from RDTs and to test the field applicability for the purpose of molecular epidemiological investigations. Methods DNA was extracted from two RDT devices (Paracheck-Pf® and SD Bioline Malaria Pf/Pan®), seeded in vitro with 10-fold dilutions of cultured 3D7 P. falciparum parasites diluted in malaria negative whole blood. The level of P. falciparum detection was determined for each extraction method and RDT device with multiple nested-PCR and real-time PCR assays. The field applicability was tested on 855 paired RDT (Paracheck-Pf) and filter paper (Whatman® 3MM) blood samples (734 RDT negative and 121 RDT positive samples) collected from febrile patients in Zanzibar 2010. RDT positive samples were genotyped at four key single nucleotide polymorphisms (SNPs) in pfmdr1 and pfcrt as well as for pfmdr1 copy number, all associated with anti-malarial drug resistance. Results The P. falciparum DNA detection limit varied with RDT device and extraction method. Chelex-100 extraction performed best for all extraction matrixes. There was no statistically significant difference in PCR detection rates in DNA extracted from RDTs and filter paper field samples. Similarly there were no significant differences in the PCR success rates and genotyping outcomes for the respective SNPs in the 121 RDT positive samples. Conclusions The results support RDTs as a valuable source of parasite DNA and provide evidence for RDT-DNA extraction for improved malaria case detection, molecular drug resistance surveillance, and RDT quality control.
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Affiliation(s)
- Ulrika Morris
- Malaria Research, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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Fröberg G, Jörnhagen L, Morris U, Shakely D, Msellem MI, Gil JP, Björkman A, Mårtensson A. Decreased prevalence of Plasmodium falciparum resistance markers to amodiaquine despite its wide scale use as ACT partner drug in Zanzibar. Malar J 2012; 11:321. [PMID: 22966778 PMCID: PMC3468380 DOI: 10.1186/1475-2875-11-321] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [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: 07/16/2012] [Accepted: 09/04/2012] [Indexed: 01/16/2023] Open
Abstract
Background Zanzibar has recently undergone a rapid decline in Plasmodium falciparum transmission following combined malaria control interventions with artemisinin-based combination therapy (ACT) and integrated vector control. Artesunate-amodiaquine (ASAQ) was implemented as first-line treatment for uncomplicated P. falciparum malaria in Zanzibar in 2003. Resistance to amodiaquine has been associated with the single nucleotide polymorphism (SNP) alleles pfcrt 76T, pfmdr1 86Y, 184Y and 1246Y. An accumulation of these SNP alleles in the parasite population over time might threaten ASAQ efficacy. The aim of this study was to assess whether prolonged use of ASAQ as first-line anti-malarial treatment selects for P. falciparum SNPs associated with resistance to the ACT partner drug amodiaquine. Methods The individual as well as the combined SNP allele prevalence were compared in pre-treatment blood samples from patients with uncomplicated P. falciparum malaria enrolled in clinical trials conducted just prior to the introduction of ASAQ in 2002–2003 (n = 208) and seven years after wide scale use of ASAQ in 2010 (n = 122). Results There was a statistically significant decrease of pfcrt 76T (96–63%), pfmdr1 86Y (75–52%), 184Y (83–72%), 1246Y (28–16%) and the most common haplotypes pfcrt/pfmdr1 TYYD (46–26%) and TYYY (17–8%), while an increase of pfcrt/pfmdr1 KNFD (0.4–14%) and KNYD (1–12%). Conclusions This is the first observation of a decreased prevalence of pfcrt 76T, pfmdr1 86Y, 184Y and 1246Y in an African setting after several years of extensive ASAQ use as first-line treatment for uncomplicated malaria. This may support sustained efficacy of ASAQ on Zanzibar, although it was unexpected considering that all these SNPs have previously been associated with amodiaquine resistance. The underlying factors of these results are unclear. Genetic dilution by imported P. falciparum parasites from mainland Tanzania, a de-selection by artesunate per se and/or an associated fitness cost might represent contributing factors. More detailed studies on temporal trends of molecular markers associated with amodiaquine resistance are required to improve the understanding of this observation.
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Affiliation(s)
- Gabrielle Fröberg
- Malaria Research Group, Department of Medicine Solna, Retzius vag 10, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Abstract
Amodiaquine (AQ) is a 4-aminoquinoline widely used in the treatment of malaria as part of the artemisinin combination therapy (ACT). AQ is metabolised towards its main metabolite desethylamodiaquine mainly by cytochrome P450 2C8 (CYP2C8). CYP1A1 and CYP1B1 play a minor role in the metabolism but they seem to be significantly involved in the formation of the short-lived quinine-imine. To complete the genetic variation picture of the main genes involved in AQ metabolism in the Zanzibar population, previously characterised for CYP2C8, we analysed in this study CYP1A1 and CYP1B1 main genetic polymorphisms. The results obtained show a low frequency of the CYP1A1*2B/C allele (2.4%) and a high frequency of CYP1B1*6 (approximately 42%) followed by CYP1B1*2 (approximately 27%) in Zanzibar islands. Genotype data for CYP1A1 and CYP1B1 show a low incidence of fast metabolisers, revealing a relatively safe genetic background in Zanzibar's population regarding the appearance of adverse effects.
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Affiliation(s)
- I Cavaco
- Institute of Biotechnology and Bioengineering, Center of Molecular and Structural Biomedicine, University of Algarve, Faro, Portugal.
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Mårtensson A, Strömberg J, Sisowath C, Msellem MI, Gil JP, Montgomery SM, Olliaro P, Ali AS, Björkman A. Efficacy of Artesunate Plus Amodiaquine versus That of Artemether-Lumefantrine for the Treatment of Uncomplicated Childhood Plasmodium falciparum Malaria in Zanzibar, Tanzania. Clin Infect Dis 2005; 41:1079-86. [PMID: 16163624 DOI: 10.1086/444460] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2005] [Accepted: 05/30/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND This is the first clinical trial comparing the efficacy of artesunate plus amodiaquine (ASAQ) and artemether-lumefantrine (AL)--the major artemisinin-based combination therapy (ACT) candidates for treatment of malaria in Africa--that involved an extended, 42-day follow-up period, polymerase chain reaction-adjusted parasitological cure rates (PCR APCRs), and systematic analyses of genetic markers related to quinoline resistance. METHODS. A total of 408 children with uncomplicated Plasmodium falciparum malaria in Zanzibar, Tanzania, were enrolled. Children who were 6-8 months of age and/or who weighed 6-8 kg were assigned to receive ASAQ for 3 days. Children who were 9-59 months of age and who weighted > or =9 kg were randomly assigned to receive either ASAQ or AL for 3 days in standard doses. Intention-to-treat analyses were performed. RESULTS Age- and weight-adjusted PCR-APCRs by follow-up day 42 were 91% (188 of 206 patients) in the ASAQ group and 94% (185 of 197 patients) in the AL group (odds ratio [OR] for the likelihood of cure, 2.07; 95% confidence interval [CI], 0.84-5.10; P=.115). A total of 5 and 7 recrudescences occurred after day 28 in the ASAQ and AL groups, respectively. On the assumption that 10 malaria episodes with uncertain PCR results were recrudescences, PCR-APCRs decreased to 88% in the ASAQ group and to 92% in the AL group. Unadjusted cure rates by day 42 were 56% (116 of 206 patients) in the ASAQ group versus 77% (151 of 197 patients) in the AL group (OR, 2.55; 95% CI, 1.66-3.91; P<.001). Rates of reinfection by day 42 were 36% (65 of 181 patients) in the ASAQ arm versus 17% (31 of 182 patients) in the AL arm (OR, 0.37; 95% CI, 0.22-0.60; P<.001). A significant selection of P. falciparum multidrug resistance gene 1 allele 86N was found in isolates associated with reinfection after AL treatment, compared with isolates at baseline (2.2-fold increase; P<.001). CONCLUSIONS Both treatments were highly efficacious, but AL provided stronger prevention against reinfection. The high proportion of recrudescences found after day 28 and the genetic selection by the long-acting partner drug underlines the importance of long follow-up periods in clinical trials. A long follow-up duration and performance of PCR genotyping should be implemented in programmatic surveillance of antimalarial drugs.
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Affiliation(s)
- Andreas Mårtensson
- Infectious Diseases Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
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Cavaco I, Strömberg-Nörklit J, Kaneko A, Msellem MI, Dahoma M, Ribeiro VL, Bjorkman A, Gil JP. CYP2C8 polymorphism frequencies among malaria patients in Zanzibar. Eur J Clin Pharmacol 2005; 61:15-8. [PMID: 15785959 DOI: 10.1007/s00228-004-0871-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 11/07/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The determination of the prevalence of the CYP2C8 main alleles in a typical set of malaria patients in Zanzibar, as these patients represent a typical population exposed to amodiaquine, an antimalarial mainly metabolized by CYP2C8. Also, to determine for the first time the frequencies of CYP2C8 alleles in native African populations. METHODS Polymerase chain reaction-restriction fragment polymorphism for the identification of CYP2C8*1, CYP2C8*2, CYP2C8*3 and CYP2C8*4 on a random population of 165 unrelated malaria patients. RESULTS The allele frequencies found were: CYP2C8*1 (wild type, 83.4%), CYP2C8*2 (13.9%), CYP2C8*3 (2.1%) and CYP2C8*4 (0.6%). In terms of genotypes, 70.4% of the patients showed the CYP2C8*1/ CYP2C8*1 genotypes, while heterozygous between the wild type and other minor alleles were seen in 26.0%. Finally, 3.6% of the patients were homozygous for slow metabolizer alleles. The frequencies observed are equivalent to those documented for African-Americans. CONCLUSIONS CYP2C8 non-wild type alleles have a significant prevalence in the East African population studied. The consequent frequency of 3.6% of patients homozygous for slow metabolizer alleles represent a significant fraction of the population potentially in higher risk of adverse effects due to a less efficient metabolism of amodiaquine. As approximately 10(6) first-line treatments are currently performed in Zanzibar per year, this represents a non-negligible absolute number of amodiaquine exposures. This information constitutes a background for the pharmacovigilance programs presently being employed in Zanzibar.
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Affiliation(s)
- I Cavaco
- Centre for Molecular and Structural Biomedicine, Universidade do Algarve, Campus de Gambelas, Faro, 8000-117, Portugal
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