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Egger JR, Han KT, Fang H, Zhou XN, Hlaing TM, Thant M, Han ZY, Wang XX, Hong T, Platt A, Simmons R, Thane TK, Meng M, Hogue J, Markwalter CF, Thi A, Htay T, Thein ZW, Paing AK, Tun ZM, Oo SM, Aung PP, Nyunt MM, Plowe CV. Temporal Dynamics of Subclinical Malaria in Different Transmission Zones of Myanmar. Am J Trop Med Hyg 2022; 107:tpmd220027. [PMID: 35895341 PMCID: PMC9490656 DOI: 10.4269/ajtmh.22-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/12/2022] [Accepted: 05/19/2022] [Indexed: 12/03/2022] Open
Abstract
Countries in the Greater Mekong Subregion have committed to eliminate Plasmodium falciparum malaria by 2025. Subclinical malaria infections that can be detected by highly sensitive polymerase chain reaction (PCR) testing in asymptomatic individuals represent a potential impediment to this goal, although the extent to which these low-density infections contribute to transmission is unclear. To understand the temporal dynamics of subclinical malaria in this setting, a cohort of 2,705 participants from three epidemiologically distinct regions of Myanmar was screened for subclinical P. falciparum and P. vivax infection using ultrasensitive PCR (usPCR). Standard rapid diagnostic tests (RDTs) for P. falciparum were also performed. Individuals who tested positive for malaria by usPCR were followed for up to 12 weeks. Regression analysis was performed to estimate whether the baseline prevalence of infection and the count of repeated positive tests were associated with demographic, behavioral, and clinical factors. At enrollment, the prevalence of subclinical malaria infection measured by usPCR was 7.7% (1.5% P. falciparum monoinfection, 0.3% mixed P. falciparum and P. vivax, and 6.0% P. vivax monoinfection), while P. falciparum prevalence measured by RDT was just 0.2%. Prevalence varied by geography and was higher among older people and in those with outdoor exposure and travel. No difference was observed in either the prevalence or count of subclinical infection by time of year, indicating that even in low-endemicity areas, a reservoir of subclinical infection persists year-round. If low-density infections are shown to represent a significant source of transmission, identification of high-risk groups and locations may aid elimination efforts.
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Affiliation(s)
- Joseph R. Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Kay T. Han
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Huang Fang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
| | - Xiao Nong Zhou
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Tin M. Hlaing
- Defense Services Medical Research Center, Nay Pyi Taw, Myanmar
| | - Myo Thant
- Defense Services Medical Research Center, Nay Pyi Taw, Myanmar
| | - Zay Y. Han
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Xiao X. Wang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
| | - Tu Hong
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
| | - Alyssa Platt
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Thynn K. Thane
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Manfred Meng
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Joyce Hogue
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Aung Thi
- National Malaria Control Program, Myanmar Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Thura Htay
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Zaw W. Thein
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Aye K. Paing
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Zin M. Tun
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Swai M. Oo
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Poe P. Aung
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Myaing M. Nyunt
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Christopher V. Plowe
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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2
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Imwong M, Dhorda M, Myo Tun K, Thu AM, Phyo AP, Proux S, Suwannasin K, Kunasol C, Srisutham S, Duanguppama J, Vongpromek R, Promnarate C, Saejeng A, Khantikul N, Sugaram R, Thanapongpichat S, Sawangjaroen N, Sutawong K, Han KT, Htut Y, Linn K, Win AA, Hlaing TM, van der Pluijm RW, Mayxay M, Pongvongsa T, Phommasone K, Tripura R, Peto TJ, von Seidlein L, Nguon C, Lek D, Chan XHS, Rekol H, Leang R, Huch C, Kwiatkowski DP, Miotto O, Ashley EA, Kyaw MP, Pukrittayakamee S, Day NPJ, Dondorp AM, Smithuis FM, Nosten FH, White NJ. Molecular epidemiology of resistance to antimalarial drugs in the Greater Mekong subregion: an observational study. Lancet Infect Dis 2020; 20:1470-1480. [PMID: 32679084 PMCID: PMC7689289 DOI: 10.1016/s1473-3099(20)30228-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/19/2020] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Greater Mekong subregion is a recurrent source of antimalarial drug resistance in Plasmodium falciparum malaria. This study aimed to characterise the extent and spread of resistance across this entire region between 2007 and 2018. METHODS P falciparum isolates from Myanmar, Thailand, Laos, and Cambodia were obtained from clinical trials and epidemiological studies done between Jan 1, 2007, and Dec 31, 2018, and were genotyped for molecular markers (pfkelch, pfcrt, pfplasmepsin2, and pfmdr1) of antimalarial drug resistance. Genetic relatedness was assessed using microsatellite and single nucleotide polymorphism typing of flanking sequences around target genes. FINDINGS 10 632 isolates were genotyped. A single long pfkelch Cys580Tyr haplotype (from -50 kb to +31·5 kb) conferring artemisinin resistance (PfPailin) now dominates across the eastern Greater Mekong subregion. Piperaquine resistance associated with pfplasmepsin2 gene amplification and mutations in pfcrt downstream of the Lys76Thr chloroquine resistance locus has also developed. On the Thailand-Myanmar border a different pfkelch Cys580Tyr lineage rose to high frequencies before it was eliminated. Elsewhere in Myanmar the Cys580Tyr allele remains widespread at low allele frequencies. Meanwhile a single artemisinin-resistant pfkelch Phe446Ile haplotype has spread across Myanmar. Despite intense use of dihydroartemisinin-piperaquine in Kayin state, eastern Myanmar, both in treatment and mass drug administrations, no selection of piperaquine resistance markers was observed. pfmdr1 amplification, a marker of resistance to mefloquine, remains at low prevalence across the entire region. INTERPRETATION Artemisinin resistance in P falciparum is now prevalent across the Greater Mekong subregion. In the eastern Greater Mekong subregion a multidrug resistant P falciparum lineage (PfPailin) dominates. In Myanmar a long pfkelch Phe446Ile haplotype has spread widely but, by contrast with the eastern Greater Mekong subregion, there is no indication of artemisinin combination therapy (ACT) partner drug resistance from genotyping known markers, and no evidence of spread of ACT resistant P falciparum from the east to the west. There is still a window of opportunity to prevent global spread of ACT resistance. FUNDING Thailand Science Research and Innovation, Initiative 5%, Expertise France, Wellcome Trust.
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Affiliation(s)
- Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Mehul Dhorda
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Worldwide Antimalarial Resistance Network, Bangkok, Thailand
| | - Kyaw Myo Tun
- Department of Preventive and Social Medicine, Defence Services Medical Academy, Yangon, Myanmar
| | - Aung Myint Thu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand; Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Kanokon Suwannasin
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chanon Kunasol
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Suttipat Srisutham
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jureeporn Duanguppama
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Aungkana Saejeng
- Bureau of Vector-borne Diseases, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | | | - Rungniran Sugaram
- Bureau of Vector-borne Diseases, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | | | - Nongyao Sawangjaroen
- Department of Microbiology, Faculty of Science, Prince of Songkla University, Songkhla, Thailand
| | - Kreepol Sutawong
- Buntharik Hospital, Amphoe Buntharik, Ubon Ratchathani, Thailand
| | - Kay Thwe Han
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Ye Htut
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Khin Linn
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Aye Aye Win
- Department of Tropical and Infectious Diseases, University of Medicine 1, Yangon, Myanmar
| | - Tin M Hlaing
- Defence Services Medical Research Centre, Naypyitaw, Myanmar
| | - Rob W van der Pluijm
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mayfong Mayxay
- Institute of Research and Education Development, University of Health Sciences, Ministry of Health, Vientiane, Laos; Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Phonsavangnuea village, Kaysone-Phomvihan district, Savannakhet, Laos
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Rupam Tripura
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chea Nguon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Dysoley Lek
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Xin Hui S Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Huy Rekol
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Rithea Leang
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Cheah Huch
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Dominic P Kwiatkowski
- Wellcome Sanger Institute, Hinxton, UK; Medical Research Council Centre for Genomics and Global Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Olivo Miotto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Wellcome Sanger Institute, Hinxton, UK; Medical Research Council Centre for Genomics and Global Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - Myat Phone Kyaw
- Department of Medical Research, Myanmar Health Network Organization, Yangon, Myanmar
| | - Sasithon Pukrittayakamee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; The Royal Society of Thailand, Dusit, Bangkok, Thailand
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frank M Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Medical Action Myanmar, Yangon, Myanmar
| | - Francois H Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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3
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Grist EPM, Flegg JA, Humphreys G, Mas IS, Anderson TJC, Ashley EA, Day NPJ, Dhorda M, Dondorp AM, Faiz MA, Gething PW, Hien TT, Hlaing TM, Imwong M, Kindermans JM, Maude RJ, Mayxay M, McDew-White M, Menard D, Nair S, Nosten F, Newton PN, Price RN, Pukrittayakamee S, Takala-Harrison S, Smithuis F, Nguyen NT, Tun KM, White NJ, Witkowski B, Woodrow CJ, Fairhurst RM, Sibley CH, Guerin PJ. Optimal health and disease management using spatial uncertainty: a geographic characterization of emergent artemisinin-resistant Plasmodium falciparum distributions in Southeast Asia. Int J Health Geogr 2016; 15:37. [PMID: 27776514 PMCID: PMC5078981 DOI: 10.1186/s12942-016-0064-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/23/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Artemisinin-resistant Plasmodium falciparum malaria parasites are now present across much of mainland Southeast Asia, where ongoing surveys are measuring and mapping their spatial distribution. These efforts require substantial resources. Here we propose a generic 'smart surveillance' methodology to identify optimal candidate sites for future sampling and thus map the distribution of artemisinin resistance most efficiently. METHODS The approach uses the 'uncertainty' map generated iteratively by a geostatistical model to determine optimal locations for subsequent sampling. RESULTS The methodology is illustrated using recent data on the prevalence of the K13-propeller polymorphism (a genetic marker of artemisinin resistance) in the Greater Mekong Subregion. CONCLUSION This methodology, which has broader application to geostatistical mapping in general, could improve the quality and efficiency of drug resistance mapping and thereby guide practical operations to eliminate malaria in affected areas.
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Affiliation(s)
- Eric P. M. Grist
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK
| | - Jennifer A. Flegg
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,School of Mathematical Sciences, Monash University, Melbourne, Australia
| | - Georgina Humphreys
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK
| | - Ignacio Suay Mas
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK
| | - Tim J. C. Anderson
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX USA
| | - Elizabeth A. Ashley
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Mehul Dhorda
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK
| | - Arjen M. Dondorp
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - M. Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ,Dev Care Foundation and Malaria Research Group, Dhaka, Bangladesh
| | - Peter W. Gething
- Spatial Epidemiology and Ecology Group, Department of Zoology, University of Oxford, Oxford, UK
| | - Tran T. Hien
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Hospital for Tropical Disease, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tin M. Hlaing
- Defence Services Medical Research Centre, Naypyitaw, Myanmar
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Richard J. Maude
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand ,Harvard TH Chan School of Public Health, Harvard University, Boston, USA
| | - Mayfong Mayxay
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
| | - Marina McDew-White
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX USA
| | - Didier Menard
- Malaria Molecular Epidemiology Unit, Institute Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Shalini Nair
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX USA
| | - Francois Nosten
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Paul N. Newton
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Microbiology Laboratory, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
| | - Ric N. Price
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | | | - Frank Smithuis
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Nhien T. Nguyen
- Hospital for Tropical Disease, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Kyaw M. Tun
- Defence Services Medical Research Centre, Naypyitaw, Myanmar ,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Nicholas J. White
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Benoit Witkowski
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Malaria Molecular Epidemiology Unit, Institute Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Charles J. Woodrow
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK ,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Rick M. Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD USA
| | - Carol Hopkins Sibley
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Department of Genome Sciences, University of Washington, Seattle, WA USA
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7LJ UK
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4
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Tun KM, Imwong M, Lwin KM, Win AA, Hlaing TM, Hlaing T, Lin K, Kyaw MP, Plewes K, Faiz MA, Dhorda M, Cheah PY, Pukrittayakamee S, Ashley EA, Anderson TJC, Nair S, McDew-White M, Flegg JA, Grist EPM, Guerin P, Maude RJ, Smithuis F, Dondorp AM, Day NPJ, Nosten F, White NJ, Woodrow CJ. Spread of artemisinin-resistant Plasmodium falciparum in Myanmar: a cross-sectional survey of the K13 molecular marker. Lancet Infect Dis 2015; 15:415-21. [PMID: 25704894 PMCID: PMC4374103 DOI: 10.1016/s1473-3099(15)70032-0] [Citation(s) in RCA: 312] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/30/2022]
Abstract
BACKGROUND Emergence of artemisinin resistance in southeast Asia poses a serious threat to the global control of Plasmodium falciparum malaria. Discovery of the K13 marker has transformed approaches to the monitoring of artemisinin resistance, allowing introduction of molecular surveillance in remote areas through analysis of DNA. We aimed to assess the spread of artemisinin-resistant P falciparum in Myanmar by determining the relative prevalence of P falciparum parasites carrying K13-propeller mutations. METHODS We did this cross-sectional survey at malaria treatment centres at 55 sites in ten administrative regions in Myanmar, and in relevant border regions in Thailand and Bangladesh, between January, 2013, and September, 2014. K13 sequences from P falciparum infections were obtained mainly by passive case detection. We entered data into two geostatistical models to produce predictive maps of the estimated prevalence of mutations of the K13 propeller region across Myanmar. FINDINGS Overall, 371 (39%) of 940 samples carried a K13-propeller mutation. We recorded 26 different mutations, including nine mutations not described previously in southeast Asia. In seven (70%) of the ten administrative regions of Myanmar, the combined K13-mutation prevalence was more than 20%. Geospatial mapping showed that the overall prevalence of K13 mutations exceeded 10% in much of the east and north of the country. In Homalin, Sagaing Region, 25 km from the Indian border, 21 (47%) of 45 parasite samples carried K13-propeller mutations. INTERPRETATION Artemisinin resistance extends across much of Myanmar. We recorded P falciparum parasites carrying K13-propeller mutations at high prevalence next to the northwestern border with India. Appropriate therapeutic regimens should be tested urgently and implemented comprehensively if spread of artemisinin resistance to other regions is to be avoided. FUNDING Wellcome Trust-Mahidol University-Oxford Tropical Medicine Research Programme and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kyaw M Tun
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Defence Services Medical Research Centre, Naypyitaw, Myanmar
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Mahidol University, Bangkok, Thailand; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
| | - Khin M Lwin
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Aye A Win
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Institute of Medicine 1, Yangon, Myanmar
| | - Tin M Hlaing
- Defence Services Medical Research Centre, Naypyitaw, Myanmar
| | - Thaung Hlaing
- Defence Services Medical Research Centre, Naypyitaw, Myanmar; Department of Health, Ministry of Health, Naypyitaw, Myanmar
| | - Khin Lin
- Department of Medical Research, Upper Myanmar, Myanmar
| | - Myat P Kyaw
- Department of Medical Research, Lower Myanmar, Myanmar
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Dev Care Foundation, Dhaka, Bangladesh
| | - Mehul Dhorda
- WorldWide Antimalarial Resistance Network, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Elizabeth A Ashley
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tim J C Anderson
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Shalini Nair
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Marina McDew-White
- Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Jennifer A Flegg
- WorldWide Antimalarial Resistance Network, Oxford, UK; School of Mathematical Sciences, Monash University, Melbourne, Australia
| | | | | | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frank Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Medical Action Myanmar, Yangon, Myanmar
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - François Nosten
- Shoklo Malaria Research Unit, Mae Sot, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Charles J Woodrow
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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