Repeat Ivermectin Mass Drug Administrations for Malaria Control II: Protocol for a Double-blind, Cluster-Randomized, Placebo-Controlled Trial for the Integrated Control of Malaria

BACKGROUND

The gains made against malaria have stagnated since 2015, threatened further by increasing resistance to insecticides and antimalarials. Improvement in malaria control necessitates a multipronged strategy, which includes the development of novel tools. One such tool is mass drug administration (MDA) with endectocides, primarily ivermectin, which has shown promise in reducing malaria transmission through lethal and sublethal impacts on the mosquito vector.

OBJECTIVE

The primary objective of the study is to assess the impact of repeated ivermectin MDA on malaria incidence in children aged ≤10 years.

METHODS

Repeat Ivermectin MDA for Malaria Control II is a double-blind, placebo-controlled, cluster-randomized, and parallel-group trial conducted in a setting with intense seasonal malaria transmission in Southwest Burkina Faso. The study included 14 discrete villages: 7 (50%) randomized to receive standard measures (seasonal malaria chemoprevention [SMC] and bed net use for children aged 3 to 59 months) and placebo, and 7 (50%) randomized to receive standard measures and monthly ivermectin MDA at 300 μg/kg for 3 consecutive days, provided under supervision to all eligible village inhabitants, over 2 successive rainy seasons. Nonpregnant individuals >90 cm in height were eligible for ivermectin MDA, and cotreatment with ivermectin and SMC was not permitted. The primary outcome is malaria incidence in children aged ≤10 years, as assessed by active case surveillance. The secondary safety outcome of repeated ivermectin MDA was assessed through active and passive adverse event monitoring.

RESULTS

The trial intervention was conducted from July to November in 2019 and 2020, with additional sampling of humans and mosquitoes occurring through February 2022 to assess postintervention changes in transmission patterns. Additional human and entomological assessments were performed over the 2 years in a subset of households from 6 cross-sectional villages. A subset of individuals underwent additional sampling in 2020 to characterize ivermectin pharmacokinetics and pharmacodynamics. Analysis and unblinding will commence once the database has been completed, cleaned, and locked.

CONCLUSIONS

Our trial represents the first study to directly assess the impact of a novel approach for malaria control, ivermectin MDA as a mosquitocidal agent, layered into existing standard-of-care interventions. The study was designed to leverage the current SMC deployment infrastructure and will provide evidence regarding the additional benefit of ivermectin MDA in reducing malaria incidence in children.

TRIAL REGISTRATIONS

ClinicalTrials.gov NCT03967054; https://clinicaltrials.gov/ct2/show/NCT03967054 and Pan African Clinical Trials Registry PACT201907479787308; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=8219.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41197.

<i>In vivo </i>Antimalarial, Antioxidant Activities and Safety of <i>Carapa procera </i>DC. (Meliaceae)</b>

&lt;b&gt;Background and Objectives:&lt;/b&gt; &lt;i&gt;Carapa procera&lt;/i&gt; is a popular herb used by traditional healers in the western part of Burkina Faso. In a previous study, &lt;i&gt;Carapa procera &lt;/i&gt;showed interesting antiplasmodial activity &lt;i&gt;in vitro &lt;/i&gt;against &lt;i&gt;P. falciparum&lt;/i&gt;. The present study aimed to evaluate its &lt;i&gt;in vivo&lt;/i&gt; potential against malaria parasites and its safety in mice. &lt;b&gt;Materials and Methods:&lt;/b&gt; The antimalarial activity of the ethanolic extract was evaluated on &lt;i&gt;Plasmodium berghei &lt;/i&gt;Anka in the Naval Medical Research Institute (NMRI) mice using the Peters 4-day suppressive test. The acute toxicity was performed according to the Lorke method and sub-acute toxicity following the Seewaboon method. The polyphenols and flavonoids were determined by colorimetric methods. The antioxidant activity of the extract was evaluated &lt;i&gt;in vitro&lt;/i&gt; by Ferric Reducing Antioxidant Power (FRAPP) and 2,2-diphenyl-1-picrylhydrazyl (DPPH) methods. &lt;b&gt;Results:&lt;/b&gt; &lt;i&gt;Carapa procera&lt;/i&gt; had a good antiplasmodial activity at a dose of 250 mg kg&lt;sup&gt;1&lt;/sup&gt; b.wt. Phytochemical screening revealed the presence of polyphenols and flavonoids in the extracts. Soxhlet ethanolic extracts had the highest content in polyphenols and flavonoids. The antioxidant activity of Soxhlet ethanolic extracts was better than macerated extract by DPPH method and FRAP method. Besides, no mortality in mice was recorded with the soxhlet ethanolic extract. No toxic signs were observed in animals in the sub-acute toxicity test. &lt;b&gt;Conclusion:&lt;/b&gt; &lt;i&gt;Carapa procera &lt;/i&gt;soxhlet ethanolic stem bark extract had a good &lt;i&gt;in vivo&lt;/i&gt; antimalarial activity against &lt;i&gt;Plasmodium berghei &lt;/i&gt;infection in mice and the extract was relatively safe when administered orally in mice.

Chronic kidney disease and HIV in the era of antiretroviral treatment: findings from a 10-year cohort study in a west African setting

Background

It has been reported that people living with HIV in West Africa exhibited the highest risks for chronic kidney disease (CKD) in the world. Here, we aimed at determining the CKD frequency and changes in kidney function during antiretroviral treatment (ART) in a large cohort of HIV-patients followed in Burkina Faso.

Methods

We included ART-naive adults who initiated ART at the Day Care Unit of the Souro Sanou University Hospital between 01/01/2007 and 12/31/2016. We assessed the estimated glomerular filtration rate (eGFR) by serum creatinine using the Modification of Diet in Renal Disease (MDRD) equation. Following the K/DOQI recommendations, CKD was defined as eGFR < 60 ml/min/1.73m² at two consecutive measurements at least 3 months apart. The factors associated with eGFR decline or CKD were identified by mixed linear regression and Cox regression, respectively.

Results

Three thousand, one hundred and thirty-eight patients (72% women) were followed for a median (IQR) of 4.5(2.2–6.9) years. At baseline, median eGFR (IQR) was 110.7(94.4–128.4) ml/min/1.73m² and 93 (3%) patients exhibited eGFR < 60 ml/min/1.73m². The lowest-performing progressions of eGFR during the first year of ART were observed in patients with 40-49 yr. age range (− 8.3[− 11.7;-5.0] ml/min/1.73m², p < 0.001), age ≥ 50 yr. (− 6.2[− 10.7;-1.8] ml/min/1.73m², p = 0.006) and high blood pressure (HBP) (− 28.4[− 46.9;-9.9] ml/min/1.73m², p = 0.003) at ART initiation. Regarding the ART exposure in patients with normal baseline eGFR, zidovudine (AZT) with protease inhibitor (PI) (− 4.7[− 7.7;-1.6] ml/min/1.73m², p = 0.002), tenofovir (TDF) + PI (− 13.1[− 17.4;-8.7] ml/min/1.73m², p < 0.001), TDF without PI (− 3.2[− 5.0;-1.4] ml/min/1.73m², p < 0.001), stavudine (d4T) + PI (− 8.5[− 14.6–2.4] ml/min/1.73m², p = 0.006) and d4T without PI (− 5.0[− 7.6–2.4] ml/min/1.73m², p < 0.001) were associated with poorer eGFR progression. The prevalence of CKD was 0.5% and the incidence was 1.9 [1.3; 2.7] cases/1000 person-years. The risk of CKD was higher in patients with HBP (4.3[1.8;9.9], p = 0.001), 40-49 yr. patients (4.2[1.6;11.2], p = 0.004), ≥50 yr. patients (4.5[1.5;14.1], p = 0.009) and patients exposed to abacavir (ABC) or didanosine (ddI) based ART (13.1[4.0;42.9], p < 0.001).

Conclusions

Our findings do not confirm the high risk of CKD reported in previous studies of West Africans with HIV, but support the recommendations for early initiation of ART and close kidney function monitoring in patients with HBP or aged ≥40 yr.

Evaluation of the Antiplasmodial Activity and Lethality of the Leaf Extract of Cassia alata L. (Fabaceae)

OBJECTIVE

Cassia alata L. (Fabaceae), one of the three plants contained in Saye, a polyherbal antimalarial remedy was assessed for its antimalarial potential and safety in mice.

METHODOLOGY

Organic extracts were prepared from the leaves and tested on the D 10 chloroquine-sensitive strain of Plasmodium falciparum using the parasite lactate dehydrogenase assay. The 4 days suppressive test using Plasmodium berghei in mice was used to evaluate the in vivo antiplasmodial activity of the extracts. Animals were treated by oral route, once a day with 50, 100, 250 and 400 mg kg -1 b.wt., of the extracts. The acute toxicity of the extracts was assessed in mice according to Thompson and Weil method. The lethal effects of the extracts on animal's body weight, tissues, biochemical and haematological parameters were determined at 823.5, 1235.5, 1853 and 2779.5 mg kg -1 b.wt., respectively.

RESULTS

The dichloromethane/methane (1:1, v/v) extract of Cassia alata was the most active against Plasmodium falciparum. The mean percent suppression of parasitemia in mice was equal to 22.5, 41.8 and 45.2% at 50, 250 and 400 mg kg -1 b.wt., respectively. No death and no clinically significant changes were recorded in mice. The maximum non-lethal dose was more than 16875 mg kg -1 in animals. No significant changes were observed in body weight, tissues morphology, biochemical and hematological parameters at doses above or equal to 2779.5 mg kg -1 b.wt.

CONCLUSION

The dichloromethane/methanol leaf extract of Cassia alata had a good to moderate in vitro and in vivo antiplasmodial activity and was found to have low toxicity at high doses in tested animals.

THERAPEUTIC POTENTIALS OF ETHANOLIC EXTRACT OF LEAVES OF HOLARRHENA FLORIBUNDA (G. DON) DUR. AND SCHINZ (APOCYNACEAE)

BACKGROUND

Holarrhena floribunda is a plant of wide usage in the Togolese folk medicine. A previous ethnobotanical survey on the latex plants of the Maritime region of the country revealed that this plant was included in several recipes curing malaria and microbial infections. Therefore, this study aimed to seek for the effectiveness of the ethanolic extract of the plant in the treatment of these diseases.

METHODS

The antimicrobial test was performed using the agar well-diffusion and the NCCLS broth microdilution methods, while the in vivo antimalarial activity was evaluated following the four-day suppressive test of Peters. The acute toxic effects of the extract were monitored after a single oral dose (5,000 mg/kg body weight) administration in NMRI mice.

RESULTS

The results indicated that the ethanolic extract of leaves of H. floribunda was active on Staphylococcus aureus ATCC 29213 and clinical strains of Staphylococcus aureus, Salmonella typhi and Klebsiella pneumoniae with MICs ranging from 0.62 to 1.25 mg/mL. The extract also showed significant parasitaemia suppression in a dose-dependent manner. In the acute toxicity assay, the oral administration of the extract to the mice did not affect the relative weight of vital organs, and there were no signs of toxicity or death during the study period. The LD50 of the tested extract was found to be greater than 5,000 mg/kg, indicating its safety.

CONCLUSION

This study demonstrates the antibacterial and antimalarial activities of leaves of H. floribunda and then, supports its medicinal use in the treatment of microbial infections.