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Yan H, Wei S, Sui Y, Lu S, Zhang W, Feng X, Liu Y, Zhang T, Ruan W, Xia J, Lin W, Ley B, Auburn S, Li S, Li J, Wang D. Analysis of the relapse of imported Plasmodium vivax and Plasmodium ovale in five provinces of China. Malar J 2023; 22:209. [PMID: 37443070 DOI: 10.1186/s12936-023-04642-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The global battle against malaria is facing formidable challenges, particularly in controlling Plasmodium vivax and Plasmodium ovale, whose cases have not been reduced as effectively as Plasmodium falciparum because of their relapse. This study investigates the current situation and underlying factors contributing to relapse or recrudescence of imported cases of P. vivax and P. ovale, and seeks to provide a reference for reducing relapse or recrudescence in malaria-free areas and offers a scientific basis for designing strategies to prevent imported re-transmission. METHODS This study analysed imported P. vivax and P. ovale in Anhui, Zhejiang, Henan, Hubei, and Guangxi provinces during 2014-2021 by retrospective analysis. A case-control study was conducted on patients who experienced relapse or recrudescence. RESULTS From 2014 to 2021, 306 cases of P.vivax and 896 cases of P.ovale were included in the study, while 75 cases had relapse or recrudescence, including 49 cases of P. ovale (65.33%) and 26 cases of P. vivax (34.67%). Within less than 5 weeks after returning to the country, 122 cases of P. vivax (39.87%, 122/306) and 265 cases of P. ovale (29.58%, 265/896) occurred. Within less than 53 weeks, the ratio of P. vivax was 94.77% (290/306), and that of P. ovale was 89.96% (806/896). Among the cases experiencing relapse or recrudescence, only 1 case of P. vivax (1/26 3.85%) and 3 cases of P. ovale (3/49 6.12%) occurred within less than 5 weeks after the first onset, whereas 21 cases of P. vivax (21/26 80.77%) and 42 cases of P. ovale (42/49 85.71%) occurred within less than 53 weeks after the first onset. The difference in relapse or recrudescence due to different drugs and medication regimens and medical activities at various levels of medical institutions was statistically significant. CONCLUSION In areas where malaria has been eliminated, routine health screening in a scientific time frame for people returning from at-risk areas can effectively improve the efficiency of preventing re-transmission, thereby reducing prevention costs and disease burden. Preventing patients from self-treating and strengthening medication regulations in health facilities are key measures to reduce relapse or recrudescence.
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Affiliation(s)
- Hui Yan
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, 530028, China
| | - Shujiao Wei
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, 530028, China
| | - Yuan Sui
- Brown School, Washington University, St. Louis, MO, USA
| | - Shenning Lu
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (Chinese Center for Tropical Diseases Research); NHC Key Laboratory of Parasite and Vector Biology (National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention), 200025, Shanghai, China
| | - Weiwei Zhang
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, 530028, China
| | - Xiangyang Feng
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, 530028, China
| | - Ying Liu
- Henan Provincial Center for Disease Control and Prevention, Zhengzhou, 450016, China
| | - Tao Zhang
- Anhui Provincial Center for Disease Control and Prevention, Hefei, 230601, China
| | - Wei Ruan
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China
| | - Jing Xia
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, 430079, China
| | - Wen Lin
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, 430079, China
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Sarah Auburn
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Shizhu Li
- Chinese Center for Disease Control and Prevention, National Institute of Parasitic Diseases, Chinese Center for Tropical Diseases Research, WHO Collaborating Centre for Tropical Diseases, National Center for International Research on Tropical Diseases, Ministry of Science and Technology, Key Laboratory of Parasite and Vector Biology, Ministry of Health, School of Global Health, Chinese Center for Tropical Diseases Research, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jun Li
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, 530028, China.
| | - Duoquan Wang
- Chinese Center for Disease Control and Prevention, National Institute of Parasitic Diseases, Chinese Center for Tropical Diseases Research, WHO Collaborating Centre for Tropical Diseases, National Center for International Research on Tropical Diseases, Ministry of Science and Technology, Key Laboratory of Parasite and Vector Biology, Ministry of Health, School of Global Health, Chinese Center for Tropical Diseases Research, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Rahi M, Sirohi PR, Sharma A. Supervised administration of primaquine may enhance adherence to radical cure for P. vivax malaria in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100199. [PMID: 37383547 PMCID: PMC10305963 DOI: 10.1016/j.lansea.2023.100199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/21/2023] [Accepted: 03/31/2023] [Indexed: 06/30/2023]
Abstract
The Plasmodium vivax lifecycle encompasses a dormant liver-stage known as 'hypnozoite' which serves as silent reservoirs of malaria, reactivation of which results in recurring episodes of relapse with varying periodicity. This contributes to continuous transmission of malaria unamenable to control methods. The prevention of relapse requires a "radical cure" by a hypnozoitcidal drug. Primaquine (PQ) has been the recommended radical cure for this malaria. However, adherence to 14 days PQ treatment remains poor. India accounts for majority of P. vivax burden globally. However, PQ administration is not supervised in the current national programme. Supervised administration of drugs ensures compliance and improves drug regime success rate. Trials across different countries have established the effectiveness of directly observed therapy (DOT) for prevention of relapses. As India aims to eliminate malaria by 2030, it is prudent to consider DOT to ensure complete treatment of the malaria affected populations. Therefore, we recommend that the Indian malaria control programme may consider DOT of primaquine for treatment of vivax malaria. The supervised administration would entail additional direct and indirect costs but will ensure complete treatment and hence minimize the probability of relapses. This will help the country in achieving the goal of malaria elimination.
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Affiliation(s)
- Manju Rahi
- Indian Council of Medical Research, New Delhi, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, India
| | | | - Amit Sharma
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, India
- International Centre for Genetic Engineering and Biotechnology, New Delhi, India
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3
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Mekonnen DA, Abadura GS, Behaksra SW, Taffese HS, Bayissa GA, Bulto MG, Tessema TS, Tadesse FG, Gadisa E. Treatment of uncomplicated Plasmodium vivax with chloroquine plus radical cure with primaquine without G6PDd testing is safe in Arba Minch, Ethiopia: assessment of clinical and parasitological response. Malar J 2023; 22:135. [PMID: 37098510 PMCID: PMC10131480 DOI: 10.1186/s12936-023-04562-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/15/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Ethiopia rolled out primaquine nationwide in 2018 for radical cure along with chloroquine for the treatment of uncomplicated Plasmodium vivax malaria in its bid for malaria elimination by 2030. The emergence of anti-malarial drug resistance would challenge the elimination goal. There is limited evidence on the emergence of chloroquine drug resistance. The clinical and parasitological outcomes of treatment of P. vivax with chloroquine plus radical cure using low dose 14 days primaquine were assessed in an endemic area of Ethiopia. METHODS A semi-directly observed 42-days follow up in-vivo therapeutic efficacy study was conducted from October 2019 to February 2020. Plasmodium vivax mono-species infected patients (n = 102) treated with a 14 days low dose (0.25 mg/kg body weight per day) primaquine plus chloroquine (a total dose of 25 mg base/kg for 3 days) were followed for 42 days to examine clinical and parasitological outcomes. Samples collected at recruitment and days of recurrence were examined by 18 S based nested polymerase chain reaction (nPCR) and Pvmsp3α nPCR-restriction fragment length polymorphism. Asexual parasitaemia and the presence of gametocytes were assessed on the scheduled days using microscopy. Clinical symptoms, haemoglobin levels, and Hillmen urine test were also assessed. RESULTS Of the 102 patients followed in this study, no early clinical and parasitological failure was observed. All patients had adequate clinical and parasitological responses within the 28 days of follow up. Late clinical (n = 3) and parasitological (n = 6) failures were observed only after day 28. The cumulative incidence of failure was 10.9% (95% confidence interval, 5.8-19.9%) on day 42. Among the paired recurrent samples, identical clones were detected only in two samples on day 0 and day of recurrences (day 30 and 42) using Pvmsp3α genotyping. No adverse effect was detected related to the low dose 14 days primaquine administrations. CONCLUSION Co-administration of CQ with PQ in the study area is well tolerated and there was no recurrence of P. vivax before 28 days of follow up. Interpretation of CQ plus PQ efficacy should be done with caution especially when the recurrent parasitaemia occurs after day 28. Therapeutic efficacy studies with appropriate design might be informative to rule out chloroquine or primaquine drug resistance and/or metabolism in the study area.
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Affiliation(s)
- Daniel Abebe Mekonnen
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia.
- Institute of Biotechnology, Addis Ababa University, 1176, Addis Ababa, Ethiopia.
| | - Girma Shumie Abadura
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia
| | - Sinknesh Wolde Behaksra
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia
| | | | | | - Mikiyas Gebremichael Bulto
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia
| | | | - Fitsum G Tadesse
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia
| | - Endalamaw Gadisa
- Malaria and Neglected Tropical Diseases Directorate, Armauer Hansen Research Institute, 1005, Addis Ababa, Ethiopia
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Yan G, Lee MC, Zhou G, Jiang AL, Degefa T, Zhong D, Wang X, Hemming-Schroeder E, Mukabana WR, Dent AE, King CL, Hsu K, Beeson J, Githure JI, Atieli H, Githeko AK, Yewhalaw D, Kazura JW. Impact of Environmental Modifications on the Ecology, Epidemiology, and Pathogenesis of Plasmodium falciparum and Plasmodium vivax Malaria in East Africa. Am J Trop Med Hyg 2022; 107:5-13. [PMID: 36228918 PMCID: PMC9662213 DOI: 10.4269/ajtmh.21-1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 07/19/2022] [Indexed: 01/27/2023] Open
Abstract
Food insecurity, recurrent famine, and poverty threaten the health of millions of African residents. Construction of dams and rural irrigation schemes is key to solving these problems. The sub-Saharan Africa International Center of Excellence for Malaria Research addresses major knowledge gaps and challenges in Plasmodium falciparum and Plasmodium vivax malaria control and elimination in malaria-endemic areas of Kenya and Ethiopia where major investments in water resource development are taking place. This article highlights progress of the International Center of Excellence for Malaria Research in malaria vector ecology and behavior, epidemiology, and pathogenesis since its inception in 2017. Studies conducted in four field sites in Kenya and Ethiopia show that dams and irrigation increased the abundance, stability, and productivity of larval habitats, resulting in increased malaria transmission and a greater disease burden. These field studies, together with hydrological and malaria transmission modeling, enhance the ability to predict the impact of water resource development projects on vector larval ecology and malaria risks, thereby facilitating the development of optimal water and environmental management practices in the context of malaria control efforts. Intersectoral collaborations and community engagement are crucial to develop and implement cost-effective malaria control strategies that meet food security needs while controlling malaria burden in local communities.
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Affiliation(s)
- Guiyun Yan
- Program in Public Health, University of California at Irvine, Irvine, California;,Address correspondence to Guiyun Yan, Program in Public Health, Room 3038, Hewitt Hall, University of California, Irvine, CA 92697-4050, E-mail: or James W. Kazura, Center for Global Health & Diseases, Case Western Reserve University, 2109 Adelbert Road Cleveland, OH 44106, E-mail:
| | - Ming-Chieh Lee
- Program in Public Health, University of California at Irvine, Irvine, California
| | - Guofa Zhou
- Program in Public Health, University of California at Irvine, Irvine, California
| | - Ai-Ling Jiang
- Center for Hydrometeorology and Remote Sensing, Department of Civil and Environmental Engineering, University of California at Irvine, Irvine, California
| | - Teshome Degefa
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Daibin Zhong
- Program in Public Health, University of California at Irvine, Irvine, California
| | - Xiaoming Wang
- Program in Public Health, University of California at Irvine, Irvine, California
| | | | | | - Arlene E. Dent
- Center for Global Health & Diseases, Case Western Reserve University, Cleveland, Ohio
| | - Christopher L. King
- Center for Global Health & Diseases, Case Western Reserve University, Cleveland, Ohio
| | - Kuolin Hsu
- Center for Hydrometeorology and Remote Sensing, Department of Civil and Environmental Engineering, University of California at Irvine, Irvine, California
| | - James Beeson
- Burnet Institute for Medical Research and Public Health, Melbourne, Victoria, Australia
| | | | - Harrysone Atieli
- School of Public Health and Community Development, Maseno University, Kisumu, Kenya
| | - Andrew K. Githeko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Delenasaw Yewhalaw
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia;,Tropical and Infectious Diseases Research Center, Jimma University, Jimma, Ethiopia
| | - James W. Kazura
- Center for Global Health & Diseases, Case Western Reserve University, Cleveland, Ohio;,Address correspondence to Guiyun Yan, Program in Public Health, Room 3038, Hewitt Hall, University of California, Irvine, CA 92697-4050, E-mail: or James W. Kazura, Center for Global Health & Diseases, Case Western Reserve University, 2109 Adelbert Road Cleveland, OH 44106, E-mail:
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5
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Ketema T, Bacha K, Getahun K, Bassat Q. In vivo efficacy of anti-malarial drugs against clinical Plasmodium vivax malaria in Ethiopia: a systematic review and meta-analysis. Malar J 2021; 20:483. [PMID: 34952581 PMCID: PMC8709955 DOI: 10.1186/s12936-021-04016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background Ethiopia is one of the few countries in Africa where Plasmodium vivax commonly co-exists with Plasmodium falciparum, and which accounts for ~ 40% of the total number of malaria infections in the country. Regardless of the growing evidence over many decades of decreasing sensitivity of this parasite to different anti-malarial drugs, there has been no comprehensive attempt made to systematically review and meta-analyse the efficacy of different anti-malarial drugs against P. vivax in the country. However, outlining the efficacy of available anti-malarial drugs against this parasite is essential to guide recommendations for the optimal therapeutic strategy to use in clinical practice. The aim of this study was to synthesize evidence on the efficacy of anti-malarial drugs against clinical P. vivax malaria in Ethiopia. Methods All potentially relevant, peer-reviewed articles accessible in PubMed, Scopus, Web of Science, and Clinical Trial.gov electronic databases were retrieved using a search strategy combining keywords and related database-specific subject terms. Randomized controlled trials (RCTs) and non-randomized trials aiming to investigate the efficacy of anti-malarial drugs against P. vivax were included in the review. Data were analysed using Review Manager Software. Cochrane Q (χ2) and the I2 tests were used to assess heterogeneity. The funnel plot and Egger’s test were used to examine risk of publication bias. Results Out of 1294 identified citations, 14 articles that presented data on 29 treatment options were included in the analysis. These studies enrolled 2144 clinical vivax malaria patients. The pooled estimate of in vivo efficacy of anti-malarial drugs against vivax malaria in Ethiopia was 97.91% (95% CI: 97.29–98.52%), with significant heterogeneity (I2 = 86%, p < 0.0001) and publication bias (Egger’s test = -12.86, p < 0.001). Different anti-malarial drugs showed varied efficacies against vivax malaria. The duration of follow-up significantly affected the calculated efficacy of any given anti-malarial drug, with longer duration of the follow-up (42 days) associated with significantly lower efficacy than efficacy reported on day 28. Also, pooled PCR-corrected efficacy and efficacy estimated from altitudinally lower transmission settings were significantly higher than PCR-uncorrected efficacy that estimated for moderate transmission settings, respectively. Conclusion The overall efficacy of anti-malarial drugs evaluated for the treatment of vivax malaria in Ethiopia was generally high, although there was wide-ranging degree of efficacy, which was affected by the treatment options, duration of follow-up, transmission intensity, and the confirmation procedures for recurrent parasitaemia. Regardless of evidence of sporadic efficacy reduction reported in the country, chloroquine (CQ), the first-line regimen in Ethiopia, remained highly efficacious, supporting its continuous utilization for confirmed P. vivax mono-infections. The addition of primaquine (PQ) to CQ is recommended, as this is the only approved way to provide radical cure, and thus ensure sustained efficacy and longer protection against P. vivax. Continuous surveillance of the efficacy of anti-malarial drugs and clinical trials to allow robust conclusions remains necessary to proactively act against possible emergence and spread of drug-resistant P. vivax in Ethiopia. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-04016-2.
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Affiliation(s)
- Tsige Ketema
- Department of Biology, College of Natural Sciences, Jimma University, Jimma, Ethiopia. .,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Ketema Bacha
- Department of Biology, College of Natural Sciences, Jimma University, Jimma, Ethiopia
| | - Kefelegn Getahun
- Department of Geography and Environmental Studies, College of Social Sciences and Humanity, Jimma University, Jimma, Ethiopia
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Catalan Institution for Research and Advanced Studies, ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Centro de Investigação Em Saúde de Manhiça (CISM), Maputo, Mozambique.,Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
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Woon SA, Manning L, Moore BR. Antimalarials for children with Plasmodium vivax infection: Current status, challenges, and research priorities. Parasitol Int 2021; 87:102512. [PMID: 34785369 DOI: 10.1016/j.parint.2021.102512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
The aim of this narrative review is to summarise efficacy and pharmacokinetic data for Plasmodium vivax in children. The burden of P. vivax malaria in children continues to remain a significant public health issue, and the need for improved treatment regimens for this vulnerable population is critical. Relapse after re-activation of dormant liver-stage hypnozoites poses additional challenges for treatment, elimination, and control strategies for P. vivax. Whilst it is recognised that paediatric pharmacology may be significantly influenced by anatomical and physiological changes of childhood, dosing regimens often continue to be extrapolated from adult data, highlighting the need for antimalarial dosing in children to be evaluated in early phase clinical trials. This will ensure that globally recommended treatment regimens do not result in suboptimal dosing in children. Furthermore, the development of affordable paediatric formulations to enhance treatment acceptability and widespread G6PD testing to facilitate use of anti-hypnozoite treatment such as primaquine and tafenoquine, should be further prioritised. As the world prepares for malaria elimination, a renewed focus on P. vivax malaria provides an ideal opportunity to harness momentum and ensure that all populations, including children have access to safe, efficacious, and correctly dosed antimalarial therapies.
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Affiliation(s)
- Sze-Ann Woon
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Laurens Manning
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Brioni R Moore
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Curtin Medical School, Curtin University, Perth, Western Australia, Australia; Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia.
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7
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Teklehaimanot A, Teklehaimanot H, Girmay A, Woyessa A. Case Report: Primaquine Failure for Radical Cure of Plasmodium vivax Malaria in Gambella, Ethiopia. Am J Trop Med Hyg 2020; 103:415-420. [PMID: 32394882 DOI: 10.4269/ajtmh.19-0890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Failures of primaquine for the treatment of relapsed Plasmodium vivax malaria is a serious challenge to malaria elimination in Ethiopia, where P. vivax accounts for up to 40% of malaria infections. We report here occurrence of a total of 15 episodes of primaquine treatment failure for radical cure in three historical P. vivax malaria patients from Gambella, Ethiopia, during 8-16 months of follow-up in 1985-1987. The total primaquine doses received were 17.5 mg/kg, 25.8 mg/kg, and 35.8 mg/kg, respectively. These total doses are much higher than in previous reports of patients with treatment failure in Ethiopia and East Africa. The possibility of new infection was excluded for these cases as the treatment and follow-up were carried out in Addis Ababa, a malaria-free city. Recrudescences were unlikely, considering the short duration pattern of the recurrences. The cytochrome P450 2D6 (CYP2D6) status for these patients is unknown, but polymorphisms have been described in Ethiopia and may have contributed to primaquine treatment failures. It is suggested that further studies be carried out in Ethiopia to determine the prevalence and distribution of primaquine treatment failures in different ethnic groups, considering the impact of CYP2D6 polymorphisms and the potential value of increasing the primaquine dose to avoid relapse.
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Affiliation(s)
| | | | - Abeba Girmay
- Laboratory Department, Saint Paulos Hospital, Millennium Collage, Addis Ababa, Ethiopia
| | - Adugna Woyessa
- National Research Institute of Health, Addis Ababa, Ethiopia
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Mesa-Echeverry E, Niebles-Bolívar M, Tobón-Castaño A. Chloroquine-Primaquine Therapeutic Efficacy, Safety, and Plasma Levels in Patients with Uncomplicated Plasmodium vivax Malaria in a Colombian Pacific Region. Am J Trop Med Hyg 2019; 100:72-77. [PMID: 30457097 DOI: 10.4269/ajtmh.18-0655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In Colombia, published studies for the treatment of uncomplicated Plasmodium vivax malaria with chloroquine-primaquine (CQ-PQ) are scarce. The aim of the study was to evaluate the therapeutic efficacy and safety profile of this combination. A clinical trial was performed in adults with uncomplicated P. vivax malaria using the 28-day World Health Organization validated protocol. Patients received supervised antimalarial treatment and the primary efficacy end point was the clinical and parasitological response. Safety was assessed through adverse events surveillance, and plasma levels of antimalarial drugs were measured. A total of 77 patients were included. Adequate clinical and parasitological response rate diagnosed by thick blood smear examination was achieved in 72 of 73 patients (98.6%) with a complete 28-day follow-up. There were two parasitological therapeutic failures (TFs) (2.9%) on day 28, established by polymerase chain reaction among 68 patients, one of them with a positive film. No adverse events were detected. After completing the antimalarial treatment, all patients reached adequate plasma concentrations of CQ and desethylchloroquine (DECQ), with medians of 302.9 and 104.0 ng/mL, respectively. Uncomplicated P. vivax malaria treatment with CQ-PQ standard treatment was effective and safe in the study population; TFs were not associated with low plasma levels of CQ and DECQ.
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9
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Awab GR, Imwong M, Bancone G, Jeeyapant A, Day NPJ, White NJ, Woodrow CJ. Chloroquine-Primaquine versus Chloroquine Alone to Treat Vivax Malaria in Afghanistan: An Open Randomized Superiority Trial. Am J Trop Med Hyg 2017; 97:1782-1787. [PMID: 29141719 PMCID: PMC5805052 DOI: 10.4269/ajtmh.17-0290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 08/04/2017] [Indexed: 11/18/2022] Open
Abstract
Afghanistan's national guidelines recommend primaquine (PQ) for radical treatment of Plasmodium vivax malaria, but this is rarely implemented because of concerns over potential hemolysis in patients who have G6PD deficiency. Between August 2009 and February 2014, we conducted an open-label, randomized controlled trial of chloroquine (CQ) alone versus chloroquine plus primaquine (0.25 mg base/kg/day for 14 days) (CQ+PQ) in patients aged 6 months and older with microscopy confirmed P. vivax infection. In the CQ+PQ group, G6PD deficiency was excluded by fluorescent spot testing. The primary outcome was P. vivax recurrence assessed by survival analysis over one year follow-up. Of 593 patients enrolled, 570 attended at or after 14 days of follow-up. Plasmodium vivax recurrences occurred in 37 (13.1%) of 282 patients in the CQ+PQ arm versus 86 (29.9%) of 288 in the CQ arm (Cox proportional hazard ratio [HR] 0.37, 95% confidence interval [CI] 0.25-0.54) (intention-to-treat analysis). Protection against recurrence was greater in the first 6 months of follow-up (HR 0.082; 95% CI 0.029-0.23) than later (HR 0.65, 95% CI 0.41-1.03). Five of seven patients requiring hospital admission were considered possible cases of PQ-related hemolysis, and PQ was stopped in a further six; however, in none of these cases did hemoglobin fall by ≥ 2 g/dL or to below 7 g/dL, and genotyping did not detect any cases of Mediterranean variant G6PD deficiency. PQ 0.25 mg/kg/day for 14 days prevents relapse of P. vivax in Afghanistan. Patient visits during the first week may improve adherence. Implementation will require deployment of point-of-care phenotypic tests for G6PD deficiency.
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Affiliation(s)
- Ghulam Rahim Awab
- Medical Faculty, Nangarhar University, Jalalabad, Afghanistan
- Ministry of Public Health, Islamic Republic of Afghanistan, Kabul, Afghanistan
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Germana Bancone
- Shoklo Malaria Research Unit, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Atthanee Jeeyapant
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Charles J. Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Lo E, Hemming-Schroeder E, Yewhalaw D, Nguyen J, Kebede E, Zemene E, Getachew S, Tushune K, Zhong D, Zhou G, Petros B, Yan G. Transmission dynamics of co-endemic Plasmodium vivax and P. falciparum in Ethiopia and prevalence of antimalarial resistant genotypes. PLoS Negl Trop Dis 2017; 11:e0005806. [PMID: 28746333 PMCID: PMC5546713 DOI: 10.1371/journal.pntd.0005806] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 08/07/2017] [Accepted: 07/13/2017] [Indexed: 11/19/2022] Open
Abstract
Ethiopia is one of the few African countries where Plasmodium vivax is co-endemic with P. falciparum. Malaria transmission is seasonal and transmission intensity varies mainly by landscape and climate. Although the recent emergence of drug resistant parasites presents a major issue to malaria control in Ethiopia, little is known about the transmission pathways of parasite species and prevalence of resistant markers. This study used microsatellites to determine population diversity and gene flow patterns of P. falciparum (N = 226) and P. vivax (N = 205), as well as prevalence of drug resistant markers to infer the impact of gene flow and existing malaria treatment regimes. Plasmodium falciparum indicated a higher rate of polyclonal infections than P. vivax. Both species revealed moderate genetic diversity and similar population structure. Populations in the northern highlands were closely related to the eastern Rift Valley, but slightly distinct from the southern basin area. Gene flow via human migrations between the northern and eastern populations were frequent and mostly bidirectional. Landscape genetic analyses indicated that environmental heterogeneity and geographical distance did not constrain parasite gene flow. This may partly explain similar patterns of resistant marker prevalence. In P. falciparum, a high prevalence of mutant alleles was detected in codons related to chloroquine (pfcrt and pfmdr1) and sulfadoxine-pyrimethamine (pfdhps and pfdhfr) resistance. Over 60% of the samples showed pfmdr1 duplications. Nevertheless, no mutation was detected in pfK13 that relates to artemisinin resistance. In P. vivax, while sequences of pvcrt-o were highly conserved and less than 5% of the samples showed pvmdr duplications, over 50% of the samples had pvmdr1 976F mutation. It remains to be tested if this mutation relates to chloroquine resistance. Monitoring the extent of malaria spread and markers of drug resistance is imperative to inform policy for evidence-based antimalarial choice and interventions. To effectively reduce malaria burden in Ethiopia, control efforts should focus on seasonal migrant populations.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antimalarials/pharmacology
- Child
- Child, Preschool
- Drug Resistance
- Endemic Diseases
- Ethiopia/epidemiology
- Female
- Gene Flow
- Genes, Protozoan
- Genetics, Population
- Genotype
- Humans
- Infant
- Infant, Newborn
- Malaria, Falciparum/epidemiology
- Malaria, Falciparum/parasitology
- Malaria, Falciparum/transmission
- Malaria, Vivax/epidemiology
- Malaria, Vivax/parasitology
- Malaria, Vivax/transmission
- Male
- Microsatellite Repeats
- Middle Aged
- Plasmodium falciparum/drug effects
- Plasmodium falciparum/genetics
- Plasmodium falciparum/isolation & purification
- Plasmodium vivax/drug effects
- Plasmodium vivax/genetics
- Plasmodium vivax/isolation & purification
- Prevalence
- Young Adult
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Affiliation(s)
- Eugenia Lo
- Department of Biological Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America
- * E-mail: (EL); (GY)
| | | | - Delenasaw Yewhalaw
- Department of Medical Laboratory Sciences and Pathology, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Jennifer Nguyen
- Program in Public Health, University of California, Irvine, California, United States of America
| | - Estifanos Kebede
- Department of Medical Laboratory Sciences and Pathology, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Endalew Zemene
- Department of Medical Laboratory Sciences and Pathology, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Sisay Getachew
- College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kora Tushune
- Department of Health Services Management, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Daibin Zhong
- Program in Public Health, University of California, Irvine, California, United States of America
| | - Guofa Zhou
- Program in Public Health, University of California, Irvine, California, United States of America
| | - Beyene Petros
- College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Guiyun Yan
- Program in Public Health, University of California, Irvine, California, United States of America
- * E-mail: (EL); (GY)
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Gebreyohannes EA, Bhagavathula AS, Seid MA, Tegegn HG. Anti-malarial treatment outcomes in Ethiopia: a systematic review and meta-analysis. Malar J 2017; 16:269. [PMID: 28673348 PMCID: PMC5496337 DOI: 10.1186/s12936-017-1922-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ethiopia is among countries with a high malaria burden. There are several studies that assessed the efficacy of anti-malarial agents in the country and this systematic review and meta-analysis was performed to obtain stronger evidence on treatment outcomes of malaria from the existing literature in Ethiopia. METHODS A systematic literature search using the preferred reporting items for systematic review and meta-analysis (PRISMA) statement was conducted on studies from Pubmed, Google Scholar, and ScienceDirect databases to identify published and unpublished literature. Comprehensive meta-analysis software was used to perform all meta-analyses. The Cochrane Q and the I 2 were used to evaluate heterogeneity of studies. Random effects model was used to combine studies showing heterogeneity of Cochrane Q p < 0.10 and I 2 > 50. RESULTS Twenty-one studies were included in the final analysis with a total number of 3123 study participants. Treatment outcomes were assessed clinically and parasitologically using World Health Organization guidelines. Adequate clinical and parasitological response was used to assess treatment success at the 28th day. Overall, a significant high treatment success of 92.9% (95% CI 89.1-96.6), p < 0.001, I 2 = 98.39% was noticed. However, treatment success was higher in falciparum malaria patients treated with artemether-lumefantrine than chloroquine for Plasmodium vivax patients [98.1% (97.0-99.2), p < 0.001, I 2 = 72.55 vs 94.7% (92.6-96.2), p < 0.001, I 2 = 53.62%]. Seven studies reported the adverse drug reactions to anti-malarial treatment; of 822 participants, 344 of them were exposed to adverse drug reactions with a pooled event rate of 39.8% (14.1-65.5), p = 0.002. CONCLUSIONS On the basis of this review, anti-malarial treatment success was high (92.9%) and standard regimens showed good efficacy against Plasmodium falciparum (98.1%) and P. vivax (94.7%) infections in Ethiopia, but associated with high rates of adverse drug reactions (ADRs). However, these ADRs were not serious enough to discontinue anti-malarial treatment. The results of this study suggest that the current anti-malarial medications are effective and safe; however, greater priority should be placed on the discovery of new anti-malarial drugs to achieve successful outcomes as resistance seems inevitable since cases of anti-malarial drug resistance have been reported from other areas of the world.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Akshaya Srikanth Bhagavathula
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Mohammed Assen Seid
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Henok Getachew Tegegn
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia
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Abstract
Introduction: Relapses are important contributors to illness and morbidity in Plasmodium vivax and P. ovale infections. Relapse prevention (radical cure) with primaquine is required for optimal management, control and ultimately elimination of Plasmodium vivax malaria. A review was conducted with publications in English, French, Portuguese and Spanish using the search terms ‘P. vivax’ and ‘relapse’. Areas covered: Hypnozoites causing relapses may be activated weeks or months after initial infection. Incidence and temporal patterns of relapse varies geographically. Relapses derive from parasites either genetically similar or different from the primary infection indicating that some derive from previous infections. Malaria illness itself may activate relapse. Primaquine is the only widely available treatment for radical cure. However, it is often not given because of uncertainty over the risks of primaquine induced haemolysis when G6PD deficiency testing is unavailable. Recommended dosing of primaquine for radical cure in East Asia and Oceania is 0.5 mg base/kg/day and elsewhere is 0.25 mg base/kg/day. Alternative treatments are under investigation. Expert commentary: Geographic heterogeneity in relapse patterns and chloroquine susceptibility of P. vivax, and G6PD deficiency epidemiology mean that radical treatment should be given much more than it is today. G6PD testing should be made widely available so primaquine can be given more safely.
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Affiliation(s)
- Cindy S Chu
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,b Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Nicholas J White
- b Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,c Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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Beyene HB, Beyene MB, Ebstie YA, Desalegn Z. Efficacy of Chloroquine for the Treatment of Vivax malaria in Northwest Ethiopia. PLoS One 2016; 11:e0161483. [PMID: 27579480 PMCID: PMC5007045 DOI: 10.1371/journal.pone.0161483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/06/2016] [Indexed: 01/05/2023] Open
Abstract
Background Resistance to anti-malarials is a major challenge for effective malaria control in sub-Saharan Africa. This triggered a need for routine monitoring of the efficacy of the antimalarial drugs every two years in all malaria endemic countries. Chloroquine remained the drug of choice for the treatment of vivax malaria in Ethiopia. Though, a strong scientific evidence of chloroquine resistance to P.vivax that could have brought change of treatment regimen is yet to be established in Ethiopia, continuous and regular monitoring of drug’s efficacy is critical for establishing rational anti-malarial drug policies. This study therefore, assessed the therapeutic efficacy of Chloroquine (CQ) for the treatment of Plasmodium vivax infections in Northwestern Ethiopia. Methods An observational, 28- day therapeutic clinical efficacy study was conducted from August to December, 2014, in Northwest Ethiopia. Patients confirmed to have monoinfection of vivax malaria, aged above 6 months were included. All subjects were treated with standard chloroquine dose of 25 mg/kg for three (3) days. Parasitological and clinical outcomes of treated patients were then evaluated on days 1, 2, 3, 7, 14, 21, and 28 during the entire 28-day follow-up period. A portable spectrophotometer (HemoCue Hb 301 System, Sweden) was used to estimate hemoglobin concentration. Results A total of 69 subjects had completed follow up. Some 57/69 (82.6%) had fever at enrolment and the rest 12 patients 48 hours before enrollment. Out of total, 65/69 (94.2%) and 66/69 (95.6%) of the study subjects were free of fever by day 1 and day 2 respectively but fever was cleared in all subjects by day 3. At base line the mean asexual parasitemia was 3540 parasites/μL of blood. Parasite carriage on day 3 was 3%. The overall cure rate (an adequate and clinical parasitological response) was very high (97%) [(95% CI = 93.1–99.4)]. The time to parasite, fever and gametocyte clearance as expressed in mean (SD) was 35 (3), 25 (4.6), 28 (3.2) hours respectively. Mean hemoglobin was significantly increased (P<0.001) from 12.2 (7–15) g/dl at day 0 to 13.3 (10–16) g/dl on day 28. Conclusions In view of our findings, CQ remains efficacious for the treatment of vivax malaria in the study area. However, there is a need to monitor CQR regularly using molecular and or biochemical tools for better evaluation of treatment outcomes.
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Affiliation(s)
- Habtamu Bedimo Beyene
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Melkamu Bedimo Beyene
- Department of Public Health, College of Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yehenew Asmamaw Ebstie
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zelalem Desalegn
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Añez A, Moscoso M, Garnica C, Ascaso C. Evaluation of the paediatric dose of chloroquine in the treatment of Plasmodium vivax malaria. Malar J 2016; 15:371. [PMID: 27430284 PMCID: PMC4950695 DOI: 10.1186/s12936-016-1420-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chloroquine (CQ) continues to be the first-line medication used worldwide in the treatment of Plasmodium vivax malaria. The dose recommended by the World Health Organization is 25 mg/kg independently of the age of the subject. Nonetheless, the pharmacokinetics and pharmacodynamics of drugs in children are different from those in adults and may influence the drug concentrations in blood and become risk factors for therapeutic failure and/o resistance to CQ. METHODS This study is a secondary analysis of the data from a clinical trial in which children over 5 years of age were administered 25 mg/kg of CQ, and CQ concentrations in blood were measured at day 7 of follow-up. Models of regression and comparison were used to evaluate and compare the CQ dose taken per kg/body weight, the CQ dose calculated based on body surface area, CQ levels in blood on day 7 and the age of the population. RESULTS The younger the study population the greater the difference between the dose per kg/body weight (real dose) and that calculated according to the BSA (theoretical dose). The difference between the two doses was -181.206 mg in the 5-9 years of age group (CI 95 % -195.39; -167.02 mg) and -71.39 mg (CI 95 % -118.61; -23.99 mg) in the 10-14-year-old group. The CQ concentrations in blood on day 7 differed in patients over and under 15 years (p = 0.008). A negative correlation was found between the real and theoretical dose (difference in dose) and the age in years (R2 = 0.529, p = 0.001). A negative correlation was also found between the difference in dose (mg) and CQ concentrations on day 7 (ng/ml) (r = -0.337, p = 0.001). Children under 15 years were found to have a higher rate of therapeutic failure than those over 15 (28 vs 4.2 %, respectively) (Kaplan-Meier p = 0.005). CONCLUSIONS A CQ dose of 25 mg/kg for the treatment of P. vivax malaria may be too low in children as demonstrated by the reduction in CQ concentrations in blood at day 7 of follow-up. This under-dosage is probably associated with the higher rate of therapeutic failure found in children under 15 years (28 vs 4.3 %). These results suggest the need to review the paediatric doses of CQ currently used.
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Affiliation(s)
- Arletta Añez
- />Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain
| | - Manuel Moscoso
- />Laboratorio de Control de Calidad de Medicamentos y Toxicología del Instituto Nacional de Laboratorios en Salud. CONCAMYT-INLASA, La Paz, Bolivia
| | - Cecilia Garnica
- />Laboratorio de Control de Calidad de Medicamentos y Toxicología del Instituto Nacional de Laboratorios en Salud. CONCAMYT-INLASA, La Paz, Bolivia
| | - Carlos Ascaso
- />Departamento de Salud Pública, Universidad de Barcelona. Institut d’ Investicions Biomediques, Augusto Pi i Sunyer, Barcelona, Spain
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Seyoum D, Kifle YG, Rondeau V, Yewhalaw D, Duchateau L, Rosas-Aguirre A, Speybroeck N. Identification of different malaria patterns due to Plasmodium falciparum and Plasmodium vivax in Ethiopian children: a prospective cohort study. Malar J 2016; 15:208. [PMID: 27075667 PMCID: PMC4831103 DOI: 10.1186/s12936-016-1253-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/30/2016] [Indexed: 01/08/2023] Open
Abstract
Background The identification of epidemiological pattern of infection with Plasmodium falciparum and Plasmodium vivax in malaria-endemic area, where multiple episodes are common, is important for intervention programmes. Methods A longitudinal cohort study based on weekly house-to-house visits was conducted between July 2008 and June 2010 in 2040 children less than 10 years of age, living nearby the Gilgel-Gibe hydroelectric power dam reservoir in order to determine factors associated with increased P. vivax and P. falciparum incidence. Two types of multivariate frailty models were applied (using time-to-first malaria episode data and time-to-recurrent malaria episode data), allowing the estimation of adjusted hazard ratios (AHR) of potential risk factors (gender, age, proximity to the dam reservoir, and season) for species-specific malaria incidence. Results Of 2040 children in 96 weeks of follow up, 864 children experienced at least one malaria episode: 685 due to P. falciparum in 548 children, and 385 due to P. vivax in 316 children. Plasmodiumvivax and P. falciparum malaria incidence rates were 8.2 (95 % CI: 7.3–9.1) and 14.6 (95 % CI: 13.4–15.6) per 1000 children per month, respectively. According to the time-to-recurrent event models, children aged ≥7 years had a lower risk of presenting P. vivax episodes (AHR = 0.6; 95 % CI: 0.4–0.9), but a higher risk of P. falciparum episodes, when compared with children under ≤3 years (AHR = 1.2; 95 % CI: 1.1–1.6). In addition, P. vivax (AHR = 2.7; 95 % CI: 2.2–3.5) and P. falciparum (AHR = 16.9; 95 % CI: 14.3–20.2) episodes were respectively 2.7 and 16.9 times more frequent in the dry season than in the long rainy season. Conclusions The analysis of all malaria episodes (first and recurrent episodes) in the malaria cohort suggests different species-specific patterns of malaria disease in children, with mild seasonality in the incidence of P. vivax episodes mostly observed in younger age groups, and with marked seasonality in the incidence of P. falciparum episodes mainly seen in older children. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1253-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dinberu Seyoum
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium.,Department of Statistics, Natural Science College, Jimma University, Jimma, Ethiopia
| | - Yehenew Getachew Kifle
- Department of Statistics and Operations Research, University of Limpopo, Polokwane, 0727, South Africa
| | - Virginie Rondeau
- INSERM EMI 0338 (Biostatistics), Université Victor Segalen Bordeaux 2, 146 rue Leo Saignat, 33076, Bordeaux Cedex, France
| | - Delenasaw Yewhalaw
- Department of Laboratory Technology Science and Pathology, College of Public Health and Medical Science, Jimma University, Jimma, Ethiopia
| | - Luc Duchateau
- Department of Comparative Physiology and Biometrics, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Angel Rosas-Aguirre
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium.,Institute of Tropical Medicine "Alexander von Humboldt", Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium.
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Abstract
The relapsing peculiarity of Plasmodium vivax is one of the prime reasons for sustained global malaria transmission. Global containment of P. vivax is more challenging and crucial compared to other species for achieving total malaria control/elimination. Primaquine (PQ) failure and P. vivax relapse is a major global public health concern. Identification and characterization of different relapse strains of P. vivax prevalent across the globe should be one of the thrust areas in malaria research. Despite renewed and rising global concern by researchers on this once 'neglected' species, research and development on the very topic of P. vivax reappearance remains inadequate. Many malaria endemic countries have not mandated routine glucose-6-phosphate dehydrogenase (G6PD) testing before initiating PQ radical cure in P. vivax malaria. This results in either no PQ prescription or thoughtless prescription and administration of PQ to P. vivax patients by healthcare providers without being concerned about patients' G6PD status and associated complications. It is imperative to ascertain the G6PD status and optimum dissemination of PQ radical cure in all cases of P. vivax malaria across the globe. There persists a compelling need to develop/validate a rapid, easy-to-perform, easy-to-interpret, quality controllable, robust, and cost-effective G6PD assay. High-dose PQ of both standard and short duration appears to be safe and more effective for preventing relapses and should be practiced among patients with normal G6PD activity. Multicentric studies involving adequately representative populations across the globe with reference PQ dose must be carried out to determine the true distribution of PQ failure. Study proving role of cytochrome P450-2D6 gene in PQ metabolism and association of CYP2D6 metabolizer phenotypes and P. vivax relapse is of prime importance and should be carried forward in multicentric systems across the globe.
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Affiliation(s)
- Kumar Rishikesh
- a Department of Medicine , Kasturba Medical College, Manipal University , Madhav Nagar, Manipal 576104 , Karnataka , India.,b Tropical Medicine Research Centre, Kasturba Medical College, Manipal University , Madhav Nagar, Manipal 576104 , Karnataka , India
| | - Kavitha Saravu
- a Department of Medicine , Kasturba Medical College, Manipal University , Madhav Nagar, Manipal 576104 , Karnataka , India.,b Tropical Medicine Research Centre, Kasturba Medical College, Manipal University , Madhav Nagar, Manipal 576104 , Karnataka , India
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Carmona Fonseca J. Primaquine and relapses of Plasmodium vivax. Meta analysis of controlled clinical trials. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2015; 18:174-93. [PMID: 25651020 DOI: 10.1590/1980-5497201500010014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/31/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primaquine (PQ) is used against relapses of vivax malaria (RVM) but several aspects about dosage are unknown, as the total effective dose (TD) in a number of days. OBJECTIVE To compare PQ regimens against RVM in randomized or non randomized controlled clinical trials (CCTs). METHODOLOGY Meta analysis. Information was sought until 31 December, 2012 in Lilacs, SciELO, PubMed (Medline), Cochrane Library, Cochrane Infectious Diseases Group, Embase. Experimental studies or CCT were used, always with concurrent control group. No matter whether or not the design was randomized, close label, supervised. It is not required that the study established difference between relapse and reinfection by molecular evidence. Inclusion and exclusion criteria for articles were applied and meet the inclusion criteria constituted adequate quality to be left in the meta analysis. RESULTS 23 ECC with or without random allocation of treatment met the selection criteria. Include four schemes of TD (TD mg number of days): 210 14 = 210 mg in 14 days; 210 7 = 210 mg in 7 days, 45 to 150 mg in 3 to 10 days, 0 (not PQ). If PQ is absent, recurrences occurr 34.48% versus 19.66% with PQ 210 14 (significant difference), 210 14 showed effectiveness equal to that of 210 7. Treatments 210 7 and 210 14 were statistically better than 45 to 150 effectiveness. CONCLUSIONS The use of PQ is necessary to reduce recurrences and TD 210 mg given at 7 or 14 days is which is more effective but more studies are required to treatment 210 7.
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Galappaththy GNL, Tharyan P, Kirubakaran R. Primaquine for preventing relapse in people with Plasmodium vivax malaria treated with chloroquine. Cochrane Database Syst Rev 2013; 2013:CD004389. [PMID: 24163057 PMCID: PMC6532739 DOI: 10.1002/14651858.cd004389.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Plasmodium vivax infections are an important contributor to the malaria burden worldwide. The World Health Organization recommends a 14-day course of primaquine (0.25 mg/kg/day, giving an adult dose of 15 mg/day) to eradicate the liver stage of the parasite and prevent relapse of the disease. Many people find a 14-day primaquine regimen difficult to complete, and there is a potential risk of haemolytic anaemia in people with glucose-6-phosphate-dehydrogenase enzyme (G6PD) deficiency. This review evaluates primaquine in P. vivax, particularly alternatives to the standard 14-day course. OBJECTIVES To compare alternative primaquine regimens to the recommended 14-day regimen for preventing relapses (radical cure) in people with P. vivax malaria treated for blood stage infection with chloroquine. We also summarize trials comparing primaquine to no primaquine that led to the recommendation for the 14-day regimen. SEARCH METHODS We searched the Cochrane Infectious Diseases Group's Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS up to 8 October 2013. We checked conference proceedings, trial registries and reference lists and contacted researchers and pharmaceutical companies for eligible studies. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs comparing various primaquine dosing regimens with the standard primaquine regimen (15 mg/day for 14 days), or with no primaquine, in people with vivax malaria treated for blood stage infection with chloroquine. DATA COLLECTION AND ANALYSIS We independently assessed trial eligibility, trial quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model in meta-analyses if there was significant heterogeneity. We assessed the overall quality of the evidence using the GRADE approach. MAIN RESULTS We included 15 trials (two cluster-RCTs) of 4377 adult and child participants. Most trials excluded people with G6PD deficiency. Trials compared various regimens of primaquine with the standard primaquine regimen, or with placebo or no treatment. All trials treated blood stage infection with chloroquine. Alternative primaquine regimens compared to 14-day primaquineRelapse rates were higher over six months with the five-day primaquine regimen than the standard 14-day regimen (RR 10.05, 95% CI 2.82 to 35.86; two trials, 186 participants, moderate quality evidence). Similarly, relapse over six months was higher with three days of primaquine than the standard 14-day regimen (RR 3.18, 95% CI 2.1 to 4.81; two trials, 262 participants, moderate quality evidence; six months follow-up); and with primaquine for seven days followed up over two months, compared to 14-day primaquine (RR 2.24, 95% CI 1.24 to 4.03; one trial, 126 participants, low quality evidence).Relapse with once-weekly supervised primaquine for eight weeks was little different over nine months follow-up compared to 14-day self-administered primaquine in one small study (RR 2.97, 95% CI 0.34 to 25.87; one trial, 129 participants, very low quality evidence). Primaquine regimens compared to no primaquineThe number of people that relapsed was similar between people given five days of primaquine or given placebo or no primaquine (four trials, 2213 participants, high quality evidence; follow-up six to 15 months); but lower with 14 days of primaquine (RR 0.6; 95% CI 0.48 to 0.75; ten trials, 1740 participants, high quality evidence; follow-up seven weeks to 15 months).No serious adverse events were reported. Treatment-limiting adverse events were rare and non-serious adverse events were mild and transient. Trial authors reported that people tolerated the drugs.We did not find trials comparing higher dose primaquine regimens (0.5 mg/kg/day or more) for five days or more with the 14-day regimen. AUTHORS' CONCLUSIONS The analysis confirms the current World Health Organization recommendation for 14-day primaquine (15 mg/day) to prevent relapse of vivax malaria. Shorter primaquine regimens at the same daily dose are associated with higher relapse rates. The comparative effects with weekly primaquine are promising, but require further trials to establish equivalence or non-inferiority compared to the 14-day regimen in high malaria transmission settings.
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Affiliation(s)
| | - Prathap Tharyan
- Christian Medical CollegeSouth Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health CareCarman Block II FloorCMC Campus, BagayamVelloreIndia632002
| | - Richard Kirubakaran
- Christian Medical CollegeSouth Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health CareCarman Block II FloorCMC Campus, BagayamVelloreIndia632002
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Gogtay N, Kannan S, Thatte UM, Olliaro PL, Sinclair D. Artemisinin-based combination therapy for treating uncomplicated Plasmodium vivax malaria. Cochrane Database Syst Rev 2013; 2013:CD008492. [PMID: 24163021 PMCID: PMC6532731 DOI: 10.1002/14651858.cd008492.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Plasmodium vivax is an important cause of malaria in many parts of Asia and South America, and parasite resistance to the standard treatment (chloroquine) is now high in some parts of Oceania. This review aims to assess the current treatment options in the light of increasing chloroquine resistance. OBJECTIVES To compare artemisinin-based combination therapies (ACTs) with alternative antimalarial regimens for treating acute uncomplicated P. vivax malaria. SEARCH METHODS We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; and the metaRegister of Controlled Trials (mRCT) up to 28 March 2013 using "vivax" and "arte* OR dihydroarte*" as search terms. SELECTION CRITERIA Randomized controlled trials comparing ACTs versus standard therapy, or comparing alternative ACTs, in adults and children with uncomplicated P. vivax malaria. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for eligibility and risk of bias, and extracted data. We used recurrent parasitaemia prior to day 28 as a proxy for effective treatment of the blood stage parasite, and compared drug treatments using risk ratios (RR) and 95% confidence intervals (CIs). We used trials following patients for longer than 28 days to assess the duration of the post-treatment prophylactic effect of ACTs. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 14 trials, that enrolled 2592 participants, and were all conducted in Asia and Oceania between 2002 and 2011. ACTs versus chloroquine: ACTs clear parasites from the peripheral blood quicker than chloroquine monotherapy (parasitaemia after 24 hours of treatment: RR 0.42, 95% CI 0.36 to 0.50, four trials, 1652 participants, high quality evidence).In settings where chloroquine remains effective, ACTs are as effective as chloroquine at preventing recurrent parasitaemias before day 28 (RR 0.58, 95% CI 0.18 to 1.90, five trials, 1622 participants, high quality evidence). In four of these trials, recurrent parasitaemias before day 28 were very low following treatment with both chloroquine and ACTs. The fifth trial, from Thailand in 2011, found increased recurrent parasitaemias following treatment with chloroquine (9%), while they remained low following ACT (2%) (RR 0.25, 95% CI 0.09 to 0.66, one trial, 437 participants).ACT combinations with long half-lives probably also provide a longer prophylactic effect after treatment, with significantly fewer recurrent parasitaemias between day 28 and day 42 or day 63 (RR 0.57, 95% CI 0.40 to 0.82, three trials, 1066 participants, moderate quality evidence). One trial, from Cambodia, Thailand, India and Indonesia, gave additional primaquine to both treatment groups to reduce the risk of spontaneous relapses. Recurrent parasitaemias after day 28 were lower than seen in the trials that did not give primaquine, but the ACT still appeared to have an advantage (RR 0.27, 95% CI 0.08 to 0.94, one trial, 376 participants, low quality evidence). ACTs versus alternative ACTs: In high transmission settings, dihydroartemisinin-piperaquine is probably superior to artemether-lumefantrine, artesunate plus sulphadoxine-pyrimethamine and artesunate plus amodiaquine at preventing recurrent parasitaemias before day 28 (RR 0.20, 95% CI 0.08 to 0.49, three trials, 334 participants, moderate quality evidence).Dihydroartemisinin-piperaquine may also have an improved post-treatment prophylactic effect lasting for up to six weeks, and this effect may be present even when primaquine is also given to achieve radical cure (RR 0.21, 95% CI 0.10 to 0.46, two trials, 179 participants, low quality evidence).The data available from low transmission settings is too limited to reliably assess the relative effectiveness of ACTs. AUTHORS' CONCLUSIONS ACTs appear at least equivalent to chloroquine at effectively treating the blood stage of P. vivax infection. Even in areas where chloroquine remains effective, this finding may allow for simplified protocols for treating all forms of malaria with ACTs. In areas where chloroquine no longer cures the infection, ACTs offer an effective alternative.Dihydroartemisinin-piperaquine is the most studied ACT. It may provide a longer period of post-treatment prophylaxis than artemether-lumefantrine or artesunate plus amodiaquine. This effect may be clinically important in high transmission settings whether primaquine is also given or not.
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Affiliation(s)
- Nithya Gogtay
- Seth GS Medical College and KEM HospitalParelMumbaiIndia400 012
| | - Sridharan Kannan
- Seth GS Medical College & KEM HospitalDepartment of Clinical PharmacologyAcharya Dhonde Marg, ParelMumbaiMaharashtraIndia400012
| | - Urmila M Thatte
- Seth GS Medical College & KEM HospitalDepartment of Clinical PharmacologyAcharya Dhonde Marg, ParelMumbaiMaharashtraIndia400012
| | - Piero L Olliaro
- World Health OrganizationUNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR)1211 Geneva 27GenevaSwitzerland
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
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Miahipour A, Keshavarz H, Heidari A, Raeisi A, Rezaeian M, Rezaei S. Assessment of the efficacy of 8 weeks of primaquine for the prevention of relapse in vivax malaria patients using SSCP-PCR and sequencing in South and South-East Iran, 2008-2011. Trans R Soc Trop Med Hyg 2013; 107:420-6. [PMID: 23694816 DOI: 10.1093/trstmh/trt035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment of vivax malaria with primaquine prevents the risk of relapse. This study was designed to assess the efficacy of 8 weeks of primaquine treatment in prevention of relapse in patients with vivax malaria in south and south-east Iran by SSCP-PCR and sequencing. METHODS A total of 163 symptomatic vivax malaria cases were followed up in Hormozgan and Sistan, Baluchestan provinces in south and south-east Iran between December 2008 and December 2011. DNA was extracted from primary and secondary positive samples. A variation region of PvMSP-1 gene was selected and amplified by PCR. The obtained fragments were processed in polyacrylamide gel for single-strand conformational polymorphism (SSCP) and then sequenced. RESULTS Among 145 patients treated with chloroquine plus primaquine who completed the study period, two patients (1.4%) experienced a secondary infection after the initial episode of Plasmodium vivax. The comparison between primary and secondary isolates by SSCP indicated different banding patterns and electrophoretic mobility. Alignment of nucleotide sequences between pair primary and secondary isolates revealed dissimilar homology. Secondary isolates of both patients were considered as reinfection. Five of the 18 cases (28%) treated with chloroquine only revealed secondary infection. Analysis of nucleotide sequences and SSCP patterns indicated the relapse in all of them. CONCLUSION This survey indicates that intake of primaquine, 0.75 mg/kg, weekly for 8 consecutive weeks, is effective for the prevention of relapse in vivax cases in Iran.
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Affiliation(s)
- A Miahipour
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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In vivo efficacy of artemether-lumefantrine and chloroquine against Plasmodium vivax: a randomized open label trial in central Ethiopia. PLoS One 2013; 8:e63433. [PMID: 23717423 PMCID: PMC3661577 DOI: 10.1371/journal.pone.0063433] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 04/02/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In vivo efficacy assessments of antimalarials are essential for ensuring effective case management. In Ethiopia, chloroquine (CQ) without primaquine is the first-line treatment for Plasmodium vivax in malarious areas, but artemether-lumefantrine (AL) is also commonly used. METHODS AND FINDINGS In 2009, we conducted a 42-day efficacy study of AL or CQ for P. vivax in Oromia Regional State, Ethiopia. Individuals with P. vivax monoinfection were enrolled. Primary endpoint was day 28 cure rate. In patients with recurrent parasitemia, drug level and genotyping using microsatellite markers were assessed. Using survival analysis, uncorrected patient cure rates at day 28 were 75.7% (95% confidence interval (CI) 66.8-82.5) for AL and 90.8% (95% CI 83.6-94.9) for CQ. During the 42 days of follow-up, 41.6% (47/113) of patients in the AL arm and 31.8% (34/107) in the CQ arm presented with recurrent P. vivax infection, with the median number of days to recurrence of 28 compared to 35 days in the AL and CQ arm, respectively. Using microsatellite markers to reclassify recurrent parasitemias with a different genotype as non-treatment failures, day 28 cure rates were genotype adjusted to 91.1% (95% CI 84.1-95.1) for AL and to 97.2% (91.6-99.1) for CQ. Three patients (2.8%) with recurrent parasitemia by day 28 in the CQ arm were noted to have drug levels above 100 ng/ml. CONCLUSIONS In the short term, both AL and CQ were effective and well-tolerated for P. vivax malaria, but high rates of recurrent parasitemia were noted with both drugs. CQ provided longer post-treatment prophylaxis than AL, resulting in delayed recurrence of parasitemia. Although the current policy of species-specific treatment can be maintained for Ethiopia, the co-administration of primaquine for treatment of P. vivax malaria needs to be urgently considered to prevent relapse infections. TRIAL REGISTRATION ClinicalTrials.gov NCT01052584.
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Heidari A, Keshavarz H, Raeisi A. Therapeutic efficacy of chloroquine and primaquine for Plasmodium vivax malaria treatment in southeast Iran. Malar J 2012. [PMCID: PMC3472390 DOI: 10.1186/1475-2875-11-s1-p45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Mavrogordato A, Lever AML. A cluster of Plasmodium vivax malaria in an expedition group to Ethiopia: prophylactic efficacy of atovaquone/proguanil on liver stages of P. vivax. J Infect 2012; 65:269-74. [PMID: 22609735 DOI: 10.1016/j.jinf.2012.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/23/2012] [Accepted: 04/03/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Complete prevention of malaria especially Plasmodium falciparum is the goal of prophylaxis. A survey, designed to ascertain reasons behind the choice of malaria prophylaxis, compliance and side effects, and to gather data on acquired malaria, identified a cluster of Plasmodium vivax infection in a cohort of 33 who travelled to Ethiopia on a scientific expedition. METHODS A questionnaire based survey of travellers who took part in a scientific survey and rafting expedition in Ethiopia between October and December 2005 on their return from the expedition and two years later. RESULTS 31 of 33 subjects completed the survey fully. Evidence was obtained on factors influencing choice of, and adherence to prophylaxis and the incidence and type of malaria related to prophylaxis. Over the two year follow up period 32% of travellers developed P. vivax malaria. Of those taking Mefloquine and Doxycycline 50% and 66% respectively developed malaria, compared to none taking Atovaquone/Proguanil as prophylaxis. Awareness and management of malaria was inadequate in several cases. Failure to use Primaquine led to second relapses. CONCLUSIONS Within this cluster, prophylaxis against P. falciparum was successful. Widespread failure of prophylaxis against P. vivax malaria was documented despite the use of recommended regimes of known efficacy against the parasite. Atovaquone/Proguanil had the least side effects and afforded the highest protection. Atovaquone/Proguanil may provide previously unrecognised protection against liver stages of P. vivax.
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Fernando D, Rodrigo C, Rajapakse S. Primaquine in vivax malaria: an update and review on management issues. Malar J 2011; 10:351. [PMID: 22152065 PMCID: PMC3306765 DOI: 10.1186/1475-2875-10-351] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/12/2011] [Indexed: 01/07/2023] Open
Abstract
Primaquine was officially licensed as an anti-malarial drug by the FDA in 1952. It has remained the only FDA licensed drug capable of clearing the intra-hepatic schizonts and hypnozoites of Plasmodium vivax. This update and review focuses on five major aspects of primaquine use in treatment of vivax malaria, namely: a) evidence of efficacy of primaquine for its current indications; b) potential hazards of its widespread use, c) critical analysis of reported resistance against primaquine containing regimens; d) evidence for combining primaquine with artemisinins in areas of chloroquine resistance; and e) the potential for replacement of primaquine with newer drugs.
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Affiliation(s)
- Deepika Fernando
- Department of Parasitology, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 8, Sri Lanka.
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Santos JB, Luz FDCDO, Deckers FAL, Tauil PL. Subdoses of primaquine in overweight patients and malaria vivax relapses: report of two cases in the Federal District, Brazil. Rev Soc Bras Med Trop 2011; 43:749-50. [PMID: 21181040 DOI: 10.1590/s0037-86822010000600033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 11/05/2010] [Indexed: 11/22/2022] Open
Abstract
Two cases of malaria by Plasmodium vivax relapsed after treatment with drugs in doses recommended by the Ministry of Health are presented. Both patients were overweight and were followed in the Federal District, an area considered free from vector transmission of the disease. Radical cure was obtained after medication with the same drugs in weight proportional doses.
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Sinclair D, Gogtay N, Brand F, Olliaro P. Artemisinin-based combination therapy for treating uncomplicated Plasmodium vivax malaria. Cochrane Database Syst Rev 2011:CD008492. [PMID: 21735431 DOI: 10.1002/14651858.cd008492.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Plasmodium vivax is an important cause of malaria in many parts of Asia and South America, and resistance to the standard treatment (chloroquine) is now high in some parts of Oceania. This review aims to assess the current treatment options in the light of rising chloroquine resistance. OBJECTIVES To compare Artemisinin-based combination therapies (ACTs) with alternative antimalarial regimens for treating acute uncomplicated P.vivax malaria. SEARCH STRATEGY We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS and the metaRegister of Controlled Trials (mRCT) using "vivax" and "arte* OR dihydroarte*" as search terms. SELECTION CRITERIA Randomized controlled trials comparing ACTs versus standard therapy, or comparing alternative ACTs, in adults and children with uncomplicated P. vivax malaria. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for eligibility and risk of bias, and extracted data. Recurrent parasitaemia prior to day 28 was taken as a proxy for effective treatment of the blood stage parasite, and drugs compared using risk ratios (RR) and 95% confidence intervals (CI). Trials following patients for longer than 28 days were used to assess the duration of the post-treatment prophylactic effect of ACTs. The quality of evidence has been assessed using the GRADE methodology. MAIN RESULTS ACTs vs chloroquineIn settings where chloroquine remains effective, ACTs are equivalent at preventing recurrent parasitemias before day 28 (four trials, 1185 participants; RR 1, 95% CI 0.30 to 3.39, high quality evidence).ACT combinations with long half-lives are probably superior to chloroquine over six to eight weeks follow-up, with significantly fewer recurrent episodes 0 after day 28 (two trials, 668 participants, RR 0.47, 95% CI 0.29 to 0.76, moderate quality evidence). It is not clear if this effect is still present if primaquine is given.Dihydroartemisinin-piperaquine versus alternative ACTsDihydroartemisinin-piperaquine is the most studied ACT for the treatment of P. vivax. In high transmission settings it is probably superior to artemether-lumefantrine, artesunate plus sulphadoxine-pyrimethamine and artesunate plus amodiaquine at preventing recurrent parasitemias before day 28 (three trials, 334 participants, RR 0.20, 95% CI 0.08 to 0.49, moderate quality evidence).This advantage with dihydroartemisinin-piperaquine may last for at least six weeks even when primaquine is also given to achieve radical cure; with fewer recurrent parasitemias occurring between day 28 and day 42 (two trials, 179 participants, RR 0.21, 95% CI 0.10 to 0.46, low quality evidence).The data available from low transmission settings is too limited to make conclusions about the relative effectiveness of ACTs. AUTHORS' CONCLUSIONS ACTs appear at least equivalent to chloroquine at effectively treating the blood stage P. vivax infection. Even where chloroquine remains effective this finding may allow for simplified protocols treating all forms of malaria with ACTs.Dihydroartemisinin-piperaquine may provide a longer period of post-treatment prophylaxis than artemether-lumefantrine or artesunate plus amodiaquine, which is likely to be a function of the long elimination half-life of piperaquine. This effect may be clinically important in high transmission settings whether primaquine is also given or not.
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Affiliation(s)
- David Sinclair
- International Health Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, L3 5QA
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Ketema T, Getahun K, Bacha K. Therapeutic efficacy of chloroquine for treatment of Plasmodium vivax malaria cases in Halaba district, South Ethiopia. Parasit Vectors 2011; 4:46. [PMID: 21453465 PMCID: PMC3076248 DOI: 10.1186/1756-3305-4-46] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 03/31/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Chloroquine is an anti-malarial drug being used to treat Plasmodium vivax malaria cases in Ethiopia. However, emergence of chloroquine resistant strains of the parasite has challenged the current efficacy of the drug. Therefore, the aim of this study was to assess the effectiveness of chloroquine against P. vivax strains in one of the malaria endemic areas of Ethiopia, namely Halaba district, located in South Nations and Nationalities Peoples Region (SNNPR) of South Ethiopia RESULTS Among 87 malaria patients enrolled in the study, only 80 of them completed the 28-days follow-up. Seven of them dropped from the study for different reasons. Among those study participants that completed their follow-up, 69 were classified under the category of adequate clinical and parasitological response (ACPR). However, the remaining 11 cases were considered as under treatment failure mainly due to recurrence of parasitemia on day 7 (four patients), day 14 (six patients), and day 21 (one patient). The age of all cases of treatment failures was found to be less than 20 years. The load of parasitemia of patients with treatment failure on day of admission (4709.4/μl) was higher than day of recurrence (372.37/μl). Parasite reduction ratio (PRR) of treatment failure cases was 12.6/μl. CONCLUSION This report revealed the rise in treatment failure (13% [95% CI = 0.074 - 0.217]) as compared to earlier reports from Ethiopia. It signals the spreading of chloroquine resistant P. vivax (CRPv) strains to malaria endemic areas of Ethiopia. It is recommended that all concerned bodies should act aggressively before further expansion of the current drug resistant malaria.
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Affiliation(s)
- Tsige Ketema
- Jimma University, College of Natural Sciences, Department of Biology, P. O. Box 378, Jimma, Ethiopia
| | - Kefelegn Getahun
- Jimma University, College of Social Sciences and Law, Department of Geography and Environmental studies, P. O. Box 378, Jimma, Ethiopia
| | - Ketema Bacha
- Jimma University, College of Natural Sciences, Department of Biology, P. O. Box 378, Jimma, Ethiopia
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Yohannes AM, Teklehaimanot A, Bergqvist Y, Ringwald P. Confirmed vivax resistance to chloroquine and effectiveness of artemether-lumefantrine for the treatment of vivax malaria in Ethiopia. Am J Trop Med Hyg 2011; 84:137-40. [PMID: 21212216 DOI: 10.4269/ajtmh.2011.09-0723] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Chloroquine (CQ) is still the drug of choice for the treatment of vivax malaria in Ethiopia, whereas artemether-lumefantrine (AL) is for falciparum malaria. In this setting, clinical malaria cases are treated with AL. This necessitated the need to assess the effectiveness of AL for the treatment of Plasmodium vivax with CQ as a comparator. A total of 57 (80.3%) and 75 (85.2%) cases treated with CQ or AL, respectively, completed the study in an outpatient setting. At the end of the follow-up period of 28 days, a cumulative incidence of treatment failure of 7.5% (95% confidence interval [CI] = 2.9-18.9%) for CQ and 19% (95% CI = 11-31.6%) for AL was detected. CQ resistance was confirmed in three of five CQ treatment failures cases. The effectiveness of AL seems lower than CQ; however, the findings were not conclusive, because the AL evening doses were not supervised.
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Ashton RA, Kefyalew T, Tesfaye G, Pullan RL, Yadeta D, Reithinger R, Kolaczinski JH, Brooker S. School-based surveys of malaria in Oromia Regional State, Ethiopia: a rapid survey method for malaria in low transmission settings. Malar J 2011; 10:25. [PMID: 21288368 PMCID: PMC3039636 DOI: 10.1186/1475-2875-10-25] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 02/03/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ethiopia, malaria transmission is seasonal and unstable, with both Plasmodium falciparum and Plasmodium vivax endemic. Such spatial and temporal clustering of malaria only serves to underscore the importance of regularly collecting up-to-date malaria surveillance data to inform decision-making in malaria control. Cross-sectional school-based malaria surveys were conducted across Oromia Regional State to generate up-to-date data for planning malaria control interventions, as well as monitoring and evaluation of operational programme implementation. METHODS Two hundred primary schools were randomly selected using a stratified and weighted sampling frame; 100 children aged five to 18 years were then randomly chosen within each school. Surveys were carried out in May 2009 and from October to December 2009, to coincide with the peak of malaria transmission in different parts of Oromia. Each child was tested for malaria by expert microscopy, their haemoglobin measured and a simple questionnaire completed. Satellite-derived environmental data were used to assess ecological correlates of Plasmodium infection; Bayesian geostatistical methods and Kulldorff's spatial scan statistic were employed to investigate spatial heterogeneity. RESULTS A total 20,899 children from 197 schools provided blood samples, two selected schools were inaccessible and one school refused to participate. The overall prevalence of Plasmodium infection was found to be 0.56% (95% CI: 0.46-0.67%), with 53% of infections due to P. falciparum and 47% due to P. vivax. Of children surveyed, 17.6% (95% CI: 17.0-18.1%) were anaemic, while 46% reported sleeping under a mosquito net the previous night. Malaria was found at 30 (15%) schools to a maximum elevation of 2,187 metres, with school-level Plasmodium prevalence ranging between 0% and 14.5%. Although environmental variables were only weakly associated with P. falciparum and P. vivax infection, clusters of infection were identified within Oromia. CONCLUSION These findings demonstrate the marked spatial heterogeneity of malaria in Oromia and, in general, Ethiopia, and provide a strong epidemiological basis for planning as well as monitoring and evaluating malaria control in a setting with seasonal and unstable malaria transmission.
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Affiliation(s)
- Ruth A Ashton
- Malaria Consortium Ethiopia, PO Box 110224, Ethio-China Road, Addis Ababa, Ethiopia.
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Moonen B, Cohen JM, Snow RW, Slutsker L, Drakeley C, Smith DL, Abeyasinghe RR, Rodriguez MH, Maharaj R, Tanner M, Targett G. Operational strategies to achieve and maintain malaria elimination. Lancet 2010; 376:1592-603. [PMID: 21035841 PMCID: PMC3037542 DOI: 10.1016/s0140-6736(10)61269-x] [Citation(s) in RCA: 275] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Present elimination strategies are based on recommendations derived during the Global Malaria Eradication Program of the 1960s. However, many countries considering elimination nowadays have high intrinsic transmission potential and, without the support of a regional campaign, have to deal with the constant threat of imported cases of the disease, emphasising the need to revisit the strategies on which contemporary elimination programmes are based. To eliminate malaria, programmes need to concentrate on identification and elimination of foci of infections through both passive and active methods of case detection. This approach needs appropriate treatment of both clinical cases and asymptomatic infections, combined with targeted vector control. Draining of infectious pools entirely will not be sufficient since they could be replenished by imported malaria. Elimination will thus additionally need identification and treatment of incoming infections before they lead to transmission, or, more realistically, embarking on regional initiatives to dry up importation at its source.
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Affiliation(s)
- Bruno Moonen
- Clinton Health Access Initiative, Nairobi, Kenya.
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Lu F, Lim CS, Nam DH, Kim K, Lin K, Kim TS, Lee HW, Chen JH, Wang Y, Sattabongkot J, Han ET. Mutations in the antifolate-resistance-associated genes dihydrofolate reductase and dihydropteroate synthase in Plasmodium vivax isolates from malaria-endemic countries. Am J Trop Med Hyg 2010; 83:474-9. [PMID: 20810806 DOI: 10.4269/ajtmh.2010.10-0004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Parasite dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS) are known target enzymes of antifolate drugs used for the treatment and prophylaxis of persons with malaria. We sequenced the Plasmodium vivax dihydrofolate reductase (pvdhfr) and dihydropteroate synthase (pvdhps) genes to examine the prevalence and extent of point mutations in isolates from malaria-endemic countries. Double mutations (S58R and S117N) or quadruple mutations (F57L/I, S58R, T61M, and S117T) in the pvdhfr gene were found in isolates from Thailand (96.4%) and Myanmar (71.4%), but in only one isolate (1.0%) from Korea, where sulfadoxine-pyrimethamine has never been used. The pvdhfr point mutations correlated strongly with the pvdhps point mutations and ranged from single to triple mutations (S382A, A383G, and A553G), among isolates from Thailand, Myanmar, and Korea. These findings suggests that the prevalence of mutations in pvdhfr and pvdhps in P. vivax isolates from different malaria-endemic countries is associated with selection pressure imposed by sulfadoxine-pyrimethamine.
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Affiliation(s)
- Feng Lu
- Department of Parasitology, Kangwon National University College of Medicine, Chuncheon, Republic of Korea.
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