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Alruwaili M, Uwimana A, Sethi R, Murindahabi M, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Mbituyumuremyi A, Gutman JR, Sullivan DJ. Peripheral and Placental Prevalence of Sulfadoxine-Pyrimethamine Resistance Markers in Plasmodium falciparum among Pregnant Women in Southern Province, Rwanda. Am J Trop Med Hyg 2023; 109:1057-1062. [PMID: 37783456 PMCID: PMC10622487 DOI: 10.4269/ajtmh.23-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 10/04/2023] Open
Abstract
Intermittent preventive therapy during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in areas of moderate to high malaria transmission intensity. As a result of the increasing prevalence of SP resistance markers, IPTp-SP was withdrawn from Rwanda in 2008. Nonetheless, more recent findings suggest that SP may improve birthweight even in the face of parasite resistance, through alternative mechanisms that are independent of antimalarial effects. The prevalence of single nucleotide polymorphisms in Plasmodium falciparum dihydropteroate synthase (pfdhps) and dihydrofolate reductase (pfdhfr) genes associated with SP resistance among 148 pregnant women from 2016 to 2018 within Rwanda's Southern Province (Huye and Kamonyi districts) was measured using a ligase detection reaction-fluorescent microsphere assay. The frequency of pfdhps K540E, A581G, and the quintuple (pfdhfr N51I + C59R + S108N/pfdhps A437G + K540E) and sextuple (pfdhfr N51I + C59R + S108N/pfdhps A437G + K540E + A581G) mutant genotypes was 90%, 38%, 75%, and 28%, respectively. No significant genotype difference was seen between the two districts, which are approximately 50 km apart. Observed agreements for matched peripheral to placental blood were reported and found to be 207 of 208 (99%) for pfdhfr and 239 of 260 (92%) for pfdhps. The peripheral blood sample did not miss any pfdhfr drug-resistant mutants or pfdhps except at the S436 loci. At this level of the sextuple mutant, the antimalarial efficacy of SP for preventing low birthweight is reduced, although overall SP still exerts a nonmalarial benefit during pregnancy. This study further reveals the need to intensify preventive measures to sustain malaria control in Rwanda to keep the overall incidence of malaria during pregnancy low.
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Affiliation(s)
- Muharib Alruwaili
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka, Saudi Arabia
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Reena Sethi
- Maternal and Child Survival Program/Jhpiego, Washington, District of Columbia
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
- Roll Back Malaria, Ouagadougou, Burkina Faso
| | - Emily Piercefield
- U.S. President’s Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Noella Umulisa
- Maternal and Child Survival Program/Jhpiego, Kigali, Rwanda
| | | | - Erin Eckert
- RTI International, Washington, District of Columbia
| | - Kaendi Munguti
- U.S. President’s Malaria Initiative, U.S. Agency for International Development, Kigali, Rwanda
| | | | - Julie R. Gutman
- Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David J. Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Uwimana A, Sethi R, Murindahabi M, Ntirandeka C, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Sullivan D, Uyizeye D, Mbituyumuremyi A, Gutman JR. Effectiveness of Intermittent Screening and Treatment of Malaria in Pregnancy on Maternal and Birth Outcomes in Selected Districts in Rwanda: A Cluster Randomized Controlled Trial. Clin Infect Dis 2023; 77:127-134. [PMID: 36896967 PMCID: PMC10330390 DOI: 10.1093/cid/ciad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery. METHODS Between September 2016 and June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrollment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery. RESULTS Nine hundred seventy-five women were enrolled in ISTp and 811 in the control group. Routine ANC plus ISTp did not significantly reduce polymerase chain reaction-confirmed placental malaria compared to control (adjusted relative risk [aRR], 0.94 [95% confidence interval {CI}, .59-1.50]; P = .799). ISTp had no impact on anemia (aRR, 1.08 [95% CI, .57-2.04]; P = .821). The mean birthweight of singleton newborns was not significantly different between arms (3054 g vs 3096 g, P = .395); however, women in the ISTp arm had a higher proportion of LBW (aRR, 1.59 [95% CI, 1.02-2.49]; P = .042). CONCLUSIONS This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW. CLINICAL TRIALS REGISTRATION NCT03508349.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Reena Sethi
- Maternal and Child Survival Program–Jhpiego, Washington, District of Columbia, USA
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Emily Piercefield
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, USA
| | - Noella Umulisa
- Maternal and Child Survival Program–Jhpiego, Kigali, Rwanda
| | | | - Erin Eckert
- US PMI Impact Malaria Project, Population Services International, Washington, District of Columbia, USA
| | - Kaendi Munguti
- US Agency for International Development, US President's Malaria Initiative, Kigali, Rwanda
| | - David Sullivan
- Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Didier Uyizeye
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Julie R Gutman
- Malaria Branch, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Uwimana A, Umulisa N, Venkatesan M, Svigel SS, Zhou Z, Munyaneza T, Habimana RM, Rucogoza A, Moriarty LF, Sandford R, Piercefield E, Goldman I, Ezema B, Talundzic E, Pacheco MA, Escalante AA, Ngamije D, Mangala JLN, Kabera M, Munguti K, Murindahabi M, Brieger W, Musanabaganwa C, Mutesa L, Udhayakumar V, Mbituyumuremyi A, Halsey ES, Lucchi NW. Association of Plasmodium falciparum kelch13 R561H genotypes with delayed parasite clearance in Rwanda: an open-label, single-arm, multicentre, therapeutic efficacy study. Lancet Infect Dis 2021; 21:1120-1128. [PMID: 33864801 DOI: 10.1016/s1473-3099(21)00142-0] [Citation(s) in RCA: 184] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Partial artemisinin resistance is suspected if delayed parasite clearance (ie, persistence of parasitaemia on day 3 after treatment initiation) is observed. Validated markers of artemisinin partial resistance in southeast Asia, Plasmodium falciparum kelch13 (Pfkelch13) R561H and P574L, have been reported in Rwanda but no association with parasite clearance has been observed. We aimed to establish the efficacy of artemether-lumefantrine and genetic characterisation of Pfkelch13 alleles and their association with treatment outcomes. METHODS This open-label, single-arm, multicentre, therapeutic efficacy study was done in 2018 in three Rwandan sites: Masaka, Rukara, and Bugarama. Children aged 6-59 months with P falciparum monoinfection and fever were eligible and treated with a 3-day course of artemether-lumefantrine. Treatment response was monitored for 28 days using weekly microscopy screenings of blood samples for P falciparum. Mutations in Pfkelch13 and P falciparum multidrug resistance-1 (Pfmdr1) genes were characterised in parasites collected from enrolled participants. Analysis of flanking microsatellites surrounding Pfkelch13 was done to define the origins of the R561H mutations. The primary endpoint was PCR-corrected parasitological cure on day 28, as per WHO protocol. FINDINGS 228 participants were enrolled and 224 (98·2%) reached the study endpoint. PCR-corrected efficacies were 97·0% (95% CI 88-100) in Masaka, 93·8% (85-98) in Rukara, and 97·2% (91-100) in Bugarama. Pfkelch13 R561H mutations were present in 28 (13%) of 218 pre-treatment samples and P574L mutations were present in two (1%) pre-treatment samples. 217 (90%) of the 240 Pfmdr1 haplotypes observed in the pretreatment samples, had either the NFD (N86Y, Y184F, D1246Y) or NYD haplotype. Eight (16%) of 51 participants in Masaka and 12 (15%) of 82 participants in Rukara were microscopically positive 3 days after treatment initiation, which was associated with pre-treatment presence of Pfkelch13 R561H in Masaka (p=0·0005). Genetic analysis of Pfkelch13 R561H mutations suggest their common ancestry and local origin in Rwanda. INTERPRETATION We confirm evidence of emerging artemisinin partial resistance in Rwanda. Although artemether-lumefantrine remains efficacious, vigilance for decreasing efficacy, further characterisation of artemisinin partial resistance, and evaluation of additional antimalarials in Rwanda should be considered. FUNDING The US President's Malaria Initiative. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Noella Umulisa
- Maternal and Child Survival Program, Jhpiego, Kigali, Rwanda; PMI Impact Malaria, Kigali, Rwanda
| | - Meera Venkatesan
- US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA
| | - Samaly S Svigel
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Zhiyong Zhou
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Rafiki M Habimana
- National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Anicet Rucogoza
- National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Leah F Moriarty
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States; US President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Emily Piercefield
- US President's Malaria Initiative, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Ira Goldman
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Bryan Ezema
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Eldin Talundzic
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - M Andreína Pacheco
- Biology Department, Institute of Genomics and Evolutionary Medicine, Temple University Philadelphia, PA, USA
| | - Ananias A Escalante
- Biology Department, Institute of Genomics and Evolutionary Medicine, Temple University Philadelphia, PA, USA
| | | | - Jean-Louis N Mangala
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Michee Kabera
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Kaendi Munguti
- US President's Malaria Initiative, US Agency for International Development, Kigali, Rwanda
| | - Monique Murindahabi
- Roll Back Malaria, West and Central Africa National Malaria Control Programme, Bobo-Dioulasso, Burkina Faso
| | - William Brieger
- Bloomberg School of Public Health, Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Leon Mutesa
- Centre for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | - Eric S Halsey
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States; US President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Naomi W Lucchi
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States; US President's Malaria Initiative, US Centers for Disease Control and Prevention, Kigali, Rwanda.
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Uwimana A, Legrand E, Stokes BH, Ndikumana JLM, Warsame M, Umulisa N, Ngamije D, Munyaneza T, Mazarati JB, Munguti K, Campagne P, Criscuolo A, Ariey F, Murindahabi M, Ringwald P, Fidock DA, Mbituyumuremyi A, Menard D. Emergence and clonal expansion of in vitro artemisinin-resistant Plasmodium falciparum kelch13 R561H mutant parasites in Rwanda. Nat Med 2020; 26:1602-1608. [PMID: 32747827 PMCID: PMC7541349 DOI: 10.1038/s41591-020-1005-2] [Citation(s) in RCA: 368] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/01/2020] [Indexed: 12/24/2022]
Abstract
Artemisinin resistance (delayed P. falciparum clearance following artemisinin-based combination therapy), is widespread across Southeast Asia but to date has not been reported in Africa1–4. Here we genotyped the P. falciparum K13 (Pfkelch13) propeller domain, mutations in which can mediate artemisinin resistance5,6, in pretreatment samples collected from recent dihydroarteminisin-piperaquine and artemether-lumefantrine efficacy trials in Rwanda7. While cure rates were >95% in both treatment arms, the Pfkelch13 R561H mutation was identified in 19 of 257 (7.4%) patients at Masaka. Phylogenetic analysis revealed the expansion of an indigenous R561H lineage. Gene editing confirmed that this mutation can drive artemisinin resistance in vitro. This study provides evidence for the de novo emergence of Pfkelch13-mediated artemisinin resistance in Rwanda, potentially compromising the continued success of antimalarial chemotherapy in Africa. Identification in Rwanda of mutations in Plasmodium falciparum capable of conferring in vitro resistance to artemisinin, an essential medicine for the treatment of malaria, underscore the crucial need for surveillance in Africa to safeguard efficacy of life-saving therapies.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre (RBC), Kigali, Rwanda.
| | - Eric Legrand
- Malaria Genetics and Resistance Unit-Institut Pasteur, INSERM U1201, CNRS ERL9195, Paris, France
| | - Barbara H Stokes
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, USA
| | | | | | - Noella Umulisa
- Maternal and Child Survival Program/JHPIEGO, Baltimore, MD, USA.,Impact Malaria Rwanda, Kigali, Rwanda
| | | | - Tharcisse Munyaneza
- National Reference Laboratory (NRL), BIOS /Rwanda Biomedical Centre (RBC), Kigali, Rwanda
| | - Jean-Baptiste Mazarati
- National Reference Laboratory (NRL), BIOS /Rwanda Biomedical Centre (RBC), Kigali, Rwanda
| | | | - Pascal Campagne
- Hub de Bioinformatique et Biostatistique-Département Biologie Computationnelle, Paris, France
| | - Alexis Criscuolo
- Hub de Bioinformatique et Biostatistique-Département Biologie Computationnelle, Paris, France
| | - Frédéric Ariey
- INSERM 1016, Institut Cochin, Service de Parasitologie-Mycologie, Hôpital Cochin, Université de Paris, Paris, France
| | | | - Pascal Ringwald
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - David A Fidock
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Aimable Mbituyumuremyi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre (RBC), Kigali, Rwanda
| | - Didier Menard
- Malaria Genetics and Resistance Unit-Institut Pasteur, INSERM U1201, CNRS ERL9195, Paris, France.
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Uwimana A, Penkunas MJ, Nisingizwe MP, Warsame M, Umulisa N, Uyizeye D, Musanabaganwa C, Munyaneza T, Ntagwabira E, Hakizimana D, Muvunyi CM, Kayobotsi C, Kabera M, Murindahabi M, Mbituyumuremyi A. Efficacy of artemether–lumefantrine versus dihydroartemisinin–piperaquine for the treatment of uncomplicated malaria among children in Rwanda: an open-label, randomized controlled trial. Trans R Soc Trop Med Hyg 2019; 113:312-319. [DOI: 10.1093/trstmh/trz009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/09/2019] [Accepted: 03/06/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michael J Penkunas
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marie Paul Nisingizwe
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marian Warsame
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Noella Umulisa
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | - Didier Uyizeye
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | | | | | | | - Dieudonne Hakizimana
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | | | - Claver Kayobotsi
- Single Project Implementation Unit, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michee Kabera
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
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Eckert E, Florey LS, Tongren JE, Salgado SR, Rukundo A, Habimana JP, Hakizimana E, Munguti K, Umulisa N, Mulindahabi M, Karema C. Impact Evaluation of Malaria Control Interventions on Morbidity and All-Cause Child Mortality in Rwanda, 2000-2010. Am J Trop Med Hyg 2017; 97:99-110. [PMID: 28990918 PMCID: PMC5619936 DOI: 10.4269/ajtmh.17-0281] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/01/2017] [Indexed: 11/07/2022] Open
Abstract
The impressive decline in child mortality that occurred in Rwanda from 1996-2000 to 2006-2010 coincided with a period of rapid increase of malaria control interventions such as indoor residual spraying (IRS); insecticide-treated net (ITN) distribution and use, and improved malaria case management. The impact of these interventions was examined through ecological correlation analysis, and robust decomposition analysis of contextual factors on all-cause child mortality. Child mortality fell 61% during the evaluation period and prevalence of severe anemia in children 6-23 months declined 71% between 2005 and 2010. These changes in malaria morbidity and mortality occurred concurrently with a substantial increase in vector control activities. ITN use increased among children under five, from 4% to 70%. The IRS program began in 2007 and covered 1.3 million people in the highest burden districts by 2010. At the same time, diagnosis and treatment with an effective antimalarial expanded nationally, and included making services available to children under the age of 5 at the community level. The percentage of children under 5 who sought care for a fever increased from 26% in 2000 to 48% in 2010. Multivariable models of the change in child mortality between 2000 and 2010 using nationally representative data reveal the importance of increasing ITN ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions.
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Affiliation(s)
- Erin Eckert
- President’s Malaria Initiative (PMI), U.S. Agency for International Development (USAID), Washington, District of Columbia
| | | | - Jon Eric Tongren
- Centers for Disease Control and Prevention (CDC), PMI, Accra, Ghana
| | - S. René Salgado
- President’s Malaria Initiative (PMI), U.S. Agency for International Development (USAID), Washington, District of Columbia
| | - Alphonse Rukundo
- Malaria and Other Parasitic Diseases Division (MOPDD), Rwanda Biomedical Center, Kigali, Rwanda
| | - Jean Pierre Habimana
- Malaria and Other Parasitic Diseases Division (MOPDD), Rwanda Biomedical Center, Kigali, Rwanda
| | - Emmanuel Hakizimana
- Malaria and Other Parasitic Diseases Division (MOPDD), Rwanda Biomedical Center, Kigali, Rwanda
| | - Kaendi Munguti
- President’s Malaria Initiative (PMI), U.S. Agency for International Development (USAID), Kigali, Rwanda
| | - Noella Umulisa
- Maternal and Child Survival Program (MCSP), Jhpiego, Kigali, Rwanda
| | - Monique Mulindahabi
- Malaria and Other Parasitic Diseases Division (MOPDD), Rwanda Biomedical Center, Kigali, Rwanda
| | - Corine Karema
- Swiss Tropical and Public Health Institute and University of Basel, Switzerland
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7
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Kozycki CT, Umulisa N, Rulisa S, Mwikarago EI, Musabyimana JP, Habimana JP, Karema C, Krogstad DJ. False-negative malaria rapid diagnostic tests in Rwanda: impact of Plasmodium falciparum isolates lacking hrp2 and declining malaria transmission. Malar J 2017; 16:123. [PMID: 28320390 PMCID: PMC5359811 DOI: 10.1186/s12936-017-1768-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Rapid diagnostic tests (RDTs) for histidine rich protein 2 (HRP2) are often used to determine whether persons with fever should be treated with anti-malarials. However, Plasmodium falciparum parasites with a deletion of the hrp2 gene yield false-negative RDTs and there are concerns the sensitivity of HRP2-based RDTs may fall when the intensity of transmission decreases. Methods This observational study enrolled 9226 patients at three health centres in Rwanda from April 2014 to April 2015. It then compared the sensitivity of RDTs based on HRP2 and the Plasmodium lactate dehydrogenase (pLDH) to microscopy (thick smears) for the diagnosis of malaria. PCR was used to determine whether deletions of the histidine-rich central repeat region of the hrp2 gene (exon 2) were associated with false-negative HRP2-based RDTs. Results In comparison to microscopy, the sensitivity and specificity of HRP2- and pLDH-based RDTs were 89.5 and 86.2% and 80.2 and 94.3%, respectively. When the results for both RDTs were combined, sensitivity rose to 91.8% and specificity was 85.7%. Additionally, when smear positivity fell from 46 to 3%, the sensitivity of the HRP2-based RDT fell from 88 to 67%. Of 370 samples with false-negative HRP2 RDT results for which PCR was performed, 140 (38%) were identified as P. falciparum by PCR. Of the isolates identified as P. falciparum by PCR, 32 (23%) were negative for the hrp2 gene based on PCR. Of the 32 P. falciparum isolates negative for hrp2 by PCR, 17 (53%) were positive based on the pLDH RDT. Conclusion This prospective study of RDT performance coincided with a decline in the intensity of malaria transmission in Kibirizi (fall in slide positivity from 46 to 3%). This decline was associated with a decrease in HRP2 RDT sensitivity (from 88 to 67%). While P. falciparum isolates without the hrp2 gene were an important cause of false-negative HRP2-based RDTs, most were identified by the pLDH-based RDT. Although WHO does not recommend the use of combined HRP2/pLDH testing in sub-Saharan Africa, these results suggest that combination HRP2/pLDH-based RDTs could reduce the impact of false-negative HRP2-based RDTs for detection of symptomatic P. falciparum malaria. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1768-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Noella Umulisa
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda.,Maternal and Child Survival Programme, Jhpiego, Kigali, Rwanda
| | - Stephen Rulisa
- School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Emil I Mwikarago
- National Reference Laboratory, Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda
| | | | - Jean Pierre Habimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda
| | - Corine Karema
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Ministry of Health, Kigali, Rwanda.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Quality and Equity Healthcare, Kigali, Rwanda
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von Seidlein L, Olaosebikan R, Hendriksen ICE, Lee SJ, Adedoyin OT, Agbenyega T, Nguah SB, Bojang K, Deen JL, Evans J, Fanello CI, Gomes E, Pedro AJ, Kahabuka C, Karema C, Kivaya E, Maitland K, Mokuolu OA, Mtove G, Mwanga-Amumpaire J, Nadjm B, Nansumba M, Ngum WP, Onyamboko MA, Reyburn H, Sakulthaew T, Silamut K, Tshefu AK, Umulisa N, Gesase S, Day NPJ, White NJ, Dondorp AM. Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial. Clin Infect Dis 2012; 54:1080-90. [PMID: 22412067 PMCID: PMC3309889 DOI: 10.1093/cid/cis034] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death. Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria. Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models. Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. Clinical Trial Registration. ISRCTN50258054.
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Affiliation(s)
- Lorenz von Seidlein
- Department of Global Health, Menzies School of Health Research, Casuarina, Northern Territory, Australia.
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Dondorp AM, Fanello CI, Hendriksen ICE, Gomes E, Seni A, Chhaganlal KD, Bojang K, Olaosebikan R, Anunobi N, Maitland K, Kivaya E, Agbenyega T, Nguah SB, Evans J, Gesase S, Kahabuka C, Mtove G, Nadjm B, Deen J, Mwanga-Amumpaire J, Nansumba M, Karema C, Umulisa N, Uwimana A, Mokuolu OA, Adedoyin OT, Johnson WBR, Tshefu AK, Onyamboko MA, Sakulthaew T, Ngum WP, Silamut K, Stepniewska K, Woodrow CJ, Bethell D, Wills B, Oneko M, Peto TE, von Seidlein L, Day NPJ, White NJ. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 2010; 376:1647-57. [PMID: 21062666 PMCID: PMC3033534 DOI: 10.1016/s0140-6736(10)61924-1] [Citation(s) in RCA: 637] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria. METHODS This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054. FINDINGS 5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects. INTERPRETATION Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide. FUNDING The Wellcome Trust.
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Affiliation(s)
- Arjen M Dondorp
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Caterina I Fanello
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ilse CE Hendriksen
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Amir Seni
- Hospital Central da Beira, Beira, Mozambique
| | | | | | | | | | | | | | | | | | | | - Samwel Gesase
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | - Catherine Kahabuka
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | | | - Behzad Nadjm
- Teule Designated District Hospital, Muheza, Tanzania
| | | | | | - Margaret Nansumba
- Mbarara University of Science and Technology and Epicentre Research Base, Mbarara, Uganda
| | - Corine Karema
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Noella Umulisa
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Aline Uwimana
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | | | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Marie A Onyamboko
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Tharisara Sakulthaew
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirichada Pan Ngum
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kasia Stepniewska
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Delia Bethell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Bridget Wills
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tim E Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Nicholas PJ Day
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Correspondence to: Prof N J White, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand
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