Therapeutic efficacy of artesunate-amodiaquine and artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in Chad: clinical and genetic surveillance

BACKGROUND

Artesunate-amodiaquine (AS-AQ) and artemether-lumefantrine (AL) are the currently recommended first-and second-line therapies for uncomplicated Plasmodium falciparum infections in Chad. This study assessed the efficacy of these artemisinin-based combinations, proportion of day 3 positive patients, proportions of molecular markers associated with P. falciparum resistance to anti-malarial drugs and variable performance of HRP2-based malaria rapid diagnostic tests (RDTs).

METHODS

A single-arm prospective study assessing the efficacy of AS-AQ and AL at three sites (Doba, Kelo and Koyom) was conducted between November 2020 to January 2021. Febrile children aged 6 to 59 months with confirmed uncomplicated P. falciparum infection were enrolled sequentially first to AS-AQ and then AL at each site and followed up for 28 days. The primary endpoint was PCR-adjusted adequate clinical and parasitological response (ACPR). Samples collected on day 0 were analysed for mutations in pfkelch13, pfcrt, pfmdr-1, pfdhfr, pfdhps genes and deletions in pfhrp2/pfhrp3 genes.

RESULTS

By the end of 28-day follow-up, per-protocol PCR corrected ACPR of 97.8% (CI 95% 88.2-100) in Kelo and 100% in Doba and Kayoma were observed among AL treated patients. For ASAQ, 100% ACPR was found in all sites. All, but one patient, did not have parasites detected on day 3. Out of the 215 day 0 samples, 96.7% showed pfkelch13 wild type allele. Seven isolates carried nonsynonymous mutations not known to be associated artemisinin partial resistance (ART-R). Most of samples had a pfcrt wild type allele (79% to 89%). The most prevalent pfmdr-1 allele detected was the single mutant 184F (51.2%). For pfdhfr and pfdhps mutations, the quintuple mutant allele N51I/C59R/S108N + G437A/540E responsible for SP treatment failures in adults and children was not detected. Single deletion in the pfhrp2 and pfhrp3 gene were detected in 10/215 (4.7%) and 2/215 (0.9%), respectively. Dual pfhrp2/pfhrp3 deletions, potentially threatening the efficacy of HRP2-based RDTs, were observed in 5/215 (2.3%) isolates.

CONCLUSION

The results of this study confirm that AS-AQ and AL treatments are highly efficacious in study areas in Chad. The absence of known pfkelch13 mutations in the study sites and the high parasite clearance rate at day 3 suggest the absence of ART-R. The absence of pfdhfr/pfdhps quintuple or sextuple (quintuple + 581G) mutant supports the continued use of SP for IPTp during pregnancy. The presence of parasites with dual pfhrp2/pfhrp3 deletions, potentially threatening the efficacy of HRP2-based RDTs, warrants the continued surveillance. Trial registration ACTRN12622001476729.

Fate of Listeria monocytogenes, Salmonella typhimurium DT104, and Escherichia coli O157:H7 in Labneh as a pre- and postfermentation contaminant

Commercially pasteurized milk (approximately 2% milkfat) was heated at 85 to 87 degrees C/30 min, inoculated to contain 2,000 to 6,000 CFU/ml of Listeria monocytogenes, Salmonella typhimurium DT104, or Escherichia coli O157:H7, cultured at 43 degrees C for 4 h with a 2.0% (wt/wt) commercial yogurt starter culture, stored 12 to 14 h at 6 degrees C, and centrifuged to obtain a Labneh-like product. Alternatively, traditional salted and unsalted Labneh was prepared using a 3.0% (wt/wt) starter culture inoculum, similarly inoculated after manufacture with the aforementioned pathogens, and stored at 6 degrees C and 20 degrees C. Throughout fermentation, Listeria populations remained unchanged, whereas numbers of Salmonella increased 0.33 to 0.47 logs during the first 2 h of fermentation and decreased thereafter. E. coli populations increased 0.46 to 1.19 logs during fermentation and remained that these levels during overnight cold storage. When unsalted and salted Labneh were inoculated after manufacture, Salmonella populations decreased >2 logs in all samples after 2 days, regardless of storage temperature, with the pathogen no longer detected in 4-day-old samples. Numbers of L. monocytogenes decreased from 2.48 to 3.70 to < 1.00 to 1.95 logs after 2 days with the pathogen persisting up to 15 days in one lot of salted/unsalted Labneh stored at 6 degrees C. E. coli O157:H7 populations decreased from 3.39 to 3.7 to < 1.00 to 2.08 logs during the first 2 days, with the pathogen no longer detected in any 4-day-old samples. Inactivation rates for all three pathogens in Labneh were unrelated to storage temperature or salt content. Unlike L. monocytogenes that persisted up to 15 days in Labneh, rapid inactivation of Salmonella typhimurium DT104 and E. coli O157:H7 suggests that these emerging foodborne pathogens are of less public health concern in traditional Labneh.