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Kästner M, Hemmer CJ, Reisinger EC. [Gastrointestinal symptoms may reflect complicated falciparum malaria]. Dtsch Med Wochenschr 2024; 149:454-457. [PMID: 38565119 DOI: 10.1055/a-2256-6589] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
HISTORY A 42-year-old female presented with a two-day history of vomiting, diarrhea, fever and chills. Two weeks before she had returned to Germany from a Safari in Tanzania. She had disregarded the recommendation to take antimalarial chemoprophylaxis. CLINICAL FINDINGS AND DIAGNOSIS The thin blood film showed Plasmodium falciparum-parasitized erythrocytes, and Plasmodium falciparum malaria was diagnosed. The full blood count showed thrombocytopenia and ultrasound imaging revealed splenomegaly. Initially the criteria for complicated malaria were not fulfilled. THERAPY AND COURSE We started oral therapy with atovaquone/proguanil. The patient vomited the tablets twice. Therefore therapy was switched to intravenous artesunate. Subsequently, parasitemia dropped from 2.8 to 1.0 % within 22 hours. After 3 days of artesunate i. v., treatment could then be completed with oral atovaquone/proguanil, and the symptoms resolved. CONCLUSIONS Patients with malaria and persistent vomiting should be treated intravenously and monitored closely, as severe gastrointestinal symptoms may reflect impending organ failure. We therefore propose including persistent vomiting in the list of criteria for complicated malaria.
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Affiliation(s)
- Matthias Kästner
- Abteilung für Tropenmedizin und Infektionskrankheiten mit Sektion Nephrologie der Universitätsmedizin Rostock
| | - Christoph Josef Hemmer
- Abteilung für Tropenmedizin und Infektionskrankheiten mit Sektion Nephrologie der Universitätsmedizin Rostock
| | - Emil Christian Reisinger
- Abteilung für Tropenmedizin und Infektionskrankheiten mit Sektion Nephrologie der Universitätsmedizin Rostock
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2
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Olumide FS, Ademola AA, Olusola O, Catherine AO. Murine Malaria Model: Ketoconazole Prevented Malaria while Proguanil and Sulfadoxine/Pyrimethamine Protected against Malaria-associated Anemia and Kidney Damage. Infect Disord Drug Targets 2024; 24:e201023222469. [PMID: 37881078 DOI: 10.2174/0118715265239831231017080840] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/06/2023] [Accepted: 08/25/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The concern about the global spread of resistant malaria has made the researchers not focus only on the treatment of established infections but relatively more on the prevention of the disease. OBJECTIVE This study evaluates the chemopreventive activity of ketoconazole in a murine malarial model. METHOD Five out of seven groups of mice were pretreated for five days with proguanil (PRG), sulfadoxine/ pyrimethamine (SP), 10, 20, and 40 mg/kg body weight (b.w) of ketoconazole (KET10, KET20, and KET40), before being infected (on the sixth day) with Plasmodium berghei. Two other groups were infected-not-treated (INT) and not-infected-nor-treated (NINT). At 72 hours postinfection, five out of ten mice in each group were sacrificed to assess parasitemia, chemoprevention, hematologic, hepatic, and renal parameters. The remaining mice were observed for 28 days to determine their mean survival day post-infection (SDPI). RESULTS All ketoconazole groups, except KET10, demonstrated 100% chemoprevention and significantly higher mean SDPI (p<0.001) in relation to INT (negative control). There was no significant difference in the mean SDPI observed in KET20 in relation to PRG or NINT (healthy control). A dose-related increase (p<0.01) in the mean plasma urea was observed when ketoconazole groups were compared to one another: KET10 versus KET20 (p<0.01) and KET20 versus KET40 (p<0.01). Sulfadoxine/pyrimethamine demonstrated significantly reduced mean plasma urea (p<0.001) and creatinine (p<0.05) in relation to INT and NINT, respectively. While PRG demonstrated significantly higher mean red blood cell (RBC), hemoglobin (HGB), and hematocrit (HCT) in relation to INT. CONCLUSION Ketoconazole possesses prophylactic antimalarial activity with associated dose-related renal impairment. Sulfadoxine/pyrimethamine demonstrated renoprotective potentials, while PRG prevented malaria-associated anemia.
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Affiliation(s)
- Faniran Samuel Olumide
- Department of Anesthesia, Osun State University Teaching Hospital, Osogbo, Osun State, Nigeria
| | - Ayankunle Akeem Ademola
- Department of Pharmacology and Therapeutics, College of Health Sciences, Osun State University, Osogbo, Osun State, Nigeria
| | - Ojurongbe Olusola
- Department of Medical Microbiology & Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso, Oyo State, Nigeria
- Humboldt Research Hub -Center for Emerging & Re-emerging Infectious Diseases (HRH-CERID), Ladoke Akintola University of Technology, Ogbomoso, Oyo State, Nigeria
| | - Adekunle Olutoyin Catherine
- Department of Medical Microbiology & Parasitology, College of Health Sciences, Osun State University, Osogbo, Osun State, Nigeria
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3
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Steiner R, Kaulich A, Müller D, Schlagenhauf P. Hair concentrations of anti-malarials in returned travellers-the HAIR study: Proof of principle analysis. Travel Med Infect Dis 2023; 54:102590. [PMID: 37209974 DOI: 10.1016/j.tmaid.2023.102590] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Hair analysis to identify substance use is an established methodology. This could also be a method to monitor adherence to antimalarial drugs. We aimed to establish a methodology to determine hair concentrations of atovaquone, proguanil and mefloquine in travellers using chemoprophylaxis. METHODS A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated for simultaneous analysis of the antimalarial drugs -atovaquone (ATQ), proguanil (PRO) and mefloquine (MQ), in human hair. The hair samples from five volunteers were used for this proof-of-concept analysis. Three volunteers were taking daily atovaquone/proguanil (ATQ/PRO) chemoprophylaxis and two volunteers were using weekly mefloquine (MQ) chemoprophylaxis. RESULTS With this proof-of-principle analysis, we could show that ATQ/PRO and MQ are integrated into the hair matrix. Chemoprophylaxis could be quantified with the established method. In hair segments, maximal concentrations of 3.0 ng/mL/20 mg hair proguanil, 1.3 ng/mL/20 mg hair atovaquone and 78.3 ng/mL/20 mg hair mefloquine were measured. Moreover, malaria drug concentration changes correlated with the time interval since finishing the chemoprophylaxis regimen. CONCLUSIONS The validated method was used successfully for the analysis of antimalarial-drug positive hair samples containing atovaquone, proguanil or mefloquine. This research shows that hair can be used for adherence monitoring of chemoprophylaxis and paves the way for larger studies and optimized procedures.
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Affiliation(s)
- Regula Steiner
- Institute for Clinical Chemistry, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Anne Kaulich
- Institute for Clinical Chemistry, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Daniel Müller
- Institute for Clinical Chemistry, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Patricia Schlagenhauf
- WHO Collaborating Centre for Travellers' Health, Competence Centre for Military Medicine Biology, Division of Global and Public Health, Institute for Epidemiology, Biostatistics and Prevention, University of Zurich Centre for Travel Medicine, Hirschengraben 84, 8001, Zürich, Switzerland.
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4
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Castañeda-Mogollón D, Toppings NB, Kamaliddin C, Lang R, Kuhn S, Pillai DR. Amplicon Deep Sequencing Reveals Multiple Genetic Events Lead to Treatment Failure with Atovaquone-Proguanil in Plasmodium falciparum. Antimicrob Agents Chemother 2023; 67:e0170922. [PMID: 37154745 PMCID: PMC10269153 DOI: 10.1128/aac.01709-22] [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: 12/21/2022] [Accepted: 03/05/2023] [Indexed: 05/10/2023] Open
Abstract
Atovaquone-proguanil (AP) is used as treatment for uncomplicated malaria, and as a chemoprophylactic agent against Plasmodium falciparum. Imported malaria remains one of the top causes of fever in Canadian returning travelers. Twelve sequential whole-blood samples before and after AP treatment failure were obtained from a patient diagnosed with P. falciparum malaria upon their return from Uganda and Sudan. Ultradeep sequencing was performed on the cytb, dhfr, and dhps markers of treatment resistance before and during the episode of recrudescence. Haplotyping profiles were generated using three different approaches: msp2-3D7 agarose and capillary electrophoresis, and cpmp using amplicon deep sequencing (ADS). A complexity of infection (COI) analysis was conducted. De novo cytb Y268C mutants strains were observed during an episode of recrudescence 17 days and 16 h after the initial malaria diagnosis and AP treatment initiation. No Y268C mutant reads were observed in any of the samples prior to the recrudescence. SNPs in the dhfr and dhps genes were observed upon initial presentation. The haplotyping profiles suggest multiple clones mutating under AP selection pressure (COI > 3). Significant differences in COI were observed by capillary electrophoresis and ADS compared to the agarose gel results. ADS using cpmp revealed the lowest haplotype variation across the longitudinal analysis. Our findings highlight the value of ultra-deep sequencing methods in the understanding of P. falciparum haplotype infection dynamics. Longitudinal samples should be analyzed in genotyping studies to increase the analytical sensitivity.
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Affiliation(s)
- Daniel Castañeda-Mogollón
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Noah B. Toppings
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Claire Kamaliddin
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
| | - Raynell Lang
- Cumming School of Medicine, Department of Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Community Health Sciences, the University of Calgary, Calgary, Alberta, Canada
| | - Susan Kuhn
- Cumming School of Medicine, Department of Pediatrics, the University of Calgary, Calgary, Alberta, Canada
| | - Dylan R. Pillai
- Cumming School of Medicine, Department of Pathology & Laboratory Medicine, the University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Department of Microbiology, Immunology, and Infectious Diseases, the University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe & Joan Snyder Institute for Chronic Diseases, the University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Diagnostic & Scientific Centre, Calgary, Alberta, Canada
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Schnyder JL, de Jong HK, Bache EB, van Hest RM, Schlagenhauf P, Borrmann S, Hanscheid T, Grobusch MP. On the potential for discontinuing atovaquone-proguanil (AP) ad-hoc post-exposure and other abbreviated AP-regimens: Pharmacology, pharmacokinetics and perspectives. Travel Med Infect Dis 2022; 52:102520. [PMID: 36526126 DOI: 10.1016/j.tmaid.2022.102520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
According to current guidelines, atovaquone-proguanil (AP) malaria chemoprophylaxis should be taken once daily starting one day before travel and continued for seven days post-exposure. However, drug-sparing regimens, including discontinuing AP after leaving malaria-endemic areas are cost-saving and probably more attractive to travelers, and may thus enhance adherence. AP has causal prophylactic effects, killing malaria parasites during the hepatic stage. If early hepatic stages were already targeted by AP, AP could possibly be discontinued upon return. Pharmacokinetic data and studies on drug-sparing AP regimens suggest this to be the case. Nevertheless, the evidence is weak and considered insufficient to modify current recommendations. Field trials require large numbers of travelers and inherently suffer from the lack of a control group. Safely-designed controlled human malaria infection trials could significantly reduce study participant numbers and safely establish an effective AP abbreviated regimen which we propose as the optimal trial design to test this concept.
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Affiliation(s)
- Jenny L Schnyder
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Hanna K de Jong
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Emmanuel B Bache
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy & Clinical Pharmacology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Patricia Schlagenhauf
- University of Zurich Centre for Travel Medicine, WHO Collaborating Centre for Travelers' Health, Department of Public and Global Health, Military Medicine Biology Competence Centre, Institute for Epidemiology, Biostatistics and Prevention, Zurich, Switzerland
| | - Steffen Borrmann
- Institute of Tropical Medicine, German Centre for Infection Research (DZIF), University of Tübingen, Tübingen, Germany; Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
| | - Thomas Hanscheid
- Instituto de Microbiologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Martin P Grobusch
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands; Institute of Tropical Medicine, German Centre for Infection Research (DZIF), University of Tübingen, Tübingen, Germany; Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon; Masanga Medical Research Unit (MMRU), Masanga, Sierra Leone; Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.
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Taylor SM, Korwa S, Wu A, Green CL, Freedman B, Clapp S, Kirui JK, O’Meara WP, Njuguna FM. Monthly sulfadoxine/pyrimethamine-amodiaquine or dihydroartemisinin-piperaquine as malaria chemoprevention in young Kenyan children with sickle cell anemia: A randomized controlled trial. PLoS Med 2022; 19:e1004104. [PMID: 36215323 PMCID: PMC9591057 DOI: 10.1371/journal.pmed.1004104] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/24/2022] [Accepted: 08/26/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Children with sickle cell anemia (SCA) in areas of Africa with endemic malaria transmission are commonly prescribed malaria chemoprevention. Chemoprevention regimens vary between countries, and the comparative efficacy of prevention regimens is largely unknown. METHODS AND FINDINGS We enrolled Kenyan children aged 1 to 10 years with homozygous hemoglobin S (HbSS) in a randomized, open-label trial conducted between January 23, 2018, and December 15, 2020, in Homa Bay, Kenya. Children were assigned 1:1:1 to daily Proguanil (the standard of care), monthly sulfadoxine/pyrimethamine-amodiaquine (SP-AQ), or monthly dihydroartemisinin-piperaquine (DP) and followed monthly for 12 months. The primary outcome was the cumulative incidence of clinical malaria at 12 months, and the main secondary outcome was the cumulative incidence of painful events by self-report. Secondary outcomes included other parasitologic, hematologic, and general events. Negative binomial models were used to estimate incidence rate ratios (IRRs) per patient-year (PPY) at risk relative to Proguanil. The primary analytic population was the As-Treated population. A total of 246 children were randomized to daily Proguanil (n = 81), monthly SP-AQ (n = 83), or monthly DP (n = 82). Overall, 53.3% (n = 131) were boys and the mean age was 4.6 ± 2.5 years. The clinical malaria incidence was 0.04 episodes/PPY; relative to the daily Proguanil group, incidence rates were not significantly different in the monthly SP-AQ (IRR: 3.05, 95% confidence interval [CI]: 0.36 to 26.14; p = 0.39) and DP (IRR: 1.36, 95% CI: 0.21 to 8.85; p = 0.90) groups. Among secondary outcomes, relative to the daily Proguanil group, the incidence of painful events was not significantly different in the monthly SP-AQ and DP groups, while monthly DP was associated with a reduced rate of dactylitis (IRR: 0.47; 95% CI: 0.23 to 0.96; p = 0.038). The incidence of Plasmodium falciparum infection relative to daily Proguanil was similar in the monthly SP-AQ group (IRR 0.46; 95% CI: 0.17 to 1.20; p = 0.13) but reduced with monthly DP (IRR 0.21; 95% CI: 0.08 to 0.56; p = 0.002). Serious adverse events were common and distributed between groups, although compared to daily Proguanil (n = 2), more children died receiving monthly SP-AQ (n = 7; hazard ratio [HR] 5.44; 95% CI: 0.92 to 32.11; p = 0.064) but not DP (n = 1; HR 0.61; 95% CI 0.04 to 9.22; p = 0.89), although differences did not reach statistical significance for either SP-AQ or DP. Study limitations include the unexpectedly limited transmission of P. falciparum in the study setting, the high use of hydroxyurea, and the enhanced supportive care for trial participants, which may limit generalizability to higher-transmission settings where routine sickle cell care is more limited. CONCLUSIONS In this study with limited malaria transmission, malaria chemoprevention in Kenyan children with SCA with monthly SP-AQ or DP did not reduce clinical malaria, but DP was associated with reduced dactylitis and P. falciparum parasitization. Pragmatic studies of chemoprevention in higher malaria transmission settings are warranted. TRIAL REGISTRATION clinicaltrials.gov (NCT03178643). Pan-African Clinical Trials Registry: PACTR201707002371165.
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Affiliation(s)
- Steve M. Taylor
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - Sarah Korwa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Angie Wu
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Cynthia L. Green
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Betsy Freedman
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sheila Clapp
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | | | - Wendy P. O’Meara
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Festus M. Njuguna
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Lamb IM, Rios KT, Shukla A, Ahiya AI, Morrisey J, Mell JC, Lindner SE, Mather MW, Vaidya AB. Mitochondrially targeted proximity biotinylation and proteomic analysis in Plasmodium falciparum. PLoS One 2022; 17:e0273357. [PMID: 35984838 PMCID: PMC9390924 DOI: 10.1371/journal.pone.0273357] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/08/2022] [Indexed: 01/26/2023] Open
Abstract
Despite ongoing efforts to control malaria infection, progress in lowering the number of deaths and infections appears to have stalled. The continued high incidence of malaria infection and mortality is in part due to emergence of parasites resistant to frontline antimalarials. This highlights the need for continued identification of novel protein drug targets. Mitochondrial functions in Plasmodium falciparum, the deadliest species of human malaria parasite, are targets of validated antimalarials including atovaquone and proguanil (Malarone). Thus, there has been great interest in identifying other essential mitochondrial proteins as candidates for novel drug targets. Garnering an increased understanding of the proteomic landscape inside the P. falciparum mitochondrion will also allow us to learn about the basic biology housed within this unique organelle. We employed a proximity biotinylation technique and mass spectrometry to identify novel P. falciparum proteins putatively targeted to the mitochondrion. We fused the leader sequence of a mitochondrially targeted chaperone, Hsp60, to the promiscuous biotin ligase TurboID. Through these experiments, we generated a list of 122 "putative mitochondrial" proteins. To verify whether these proteins were indeed mitochondrial, we chose five candidate proteins of interest for localization studies using ectopic expression and tagging of each full-length protein. This allowed us to localize four candidate proteins of unknown function to the mitochondrion, three of which have previously been assessed to be essential. We suggest that phenotypic characterization of these and other proteins from this list of 122 could be fruitful in understanding the basic mitochondrial biology of these parasites and aid antimalarial drug discovery efforts.
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Affiliation(s)
- Ian M. Lamb
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Kelly T. Rios
- Department of Biochemistry and Molecular Biology, The Huck Center for Malaria Research, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Anurag Shukla
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Avantika I. Ahiya
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Joanne Morrisey
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Joshua C. Mell
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Scott E. Lindner
- Department of Biochemistry and Molecular Biology, The Huck Center for Malaria Research, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Michael W. Mather
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Akhil B. Vaidya
- Center for Molecular Parasitology, Institute for Molecular Medicine and Infectious Disease, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States of America
- * E-mail:
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8
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Enato IG, Sadoh AE, Ibadin OM, Odunvbun ME. Prevalence of Molecular Markers of Plasmodium Falciparum Resistance to Proguanil and Pyrimethamine in Children with Haemoglobin Phenotypes SS and AA in Benin City, Nigeria. West Afr J Med 2021; 38:1183-1189. [PMID: 35037448] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Chemoprophylaxis against Plasmodium falciparum (Pf) is advocated in children with sickle cell anaemia (SCA). Among them, antifolates: proguanil and pyrimethamine had replaced initial chemoprophylactic drugs because of widespread resistance. In recent past, efficacy of these antifolates has also come under scrutiny due to increasing level of drug resistance. Specific point mutations on Plasmodium falciparum dihydrofolate reductase gene (pfdhfr) have been linked with resistance to proguanil and pyrimethamine and they can be used as markers in monitoring prevalence and level of resistance to the drugs. OBJECTIVES To determine the prevalence of molecular markers of Plasmodium falciparum resistance to proguanil and pyrimethamine in children with SCA. METHODS A total of 146 Plasmodium falciparum isolates (71 from children with SCA and 75 from those with Haemoglobin AA: HbAA) were evaluated for point mutations and mutant haplotypes on the pfdhfr gene using nested polymerase chain reaction amplification followed by direct sequencing. RESULTS The triple (S108N+N51I+C59N) mutant haplotype was present in 100.0% and 96.0% of samples from children with SCA and HbAA respectively. S108T, A16V and 1164L mutationswere not present in both groups. CONCLUSION High prevalence of triple mutant haplotype mediates significant resistance to pyrimethamine and implies that pyrimethamine resistance is fixed in the study locale. However, the absence of pfdhfr S108T and A16V mutations, which indicate specific resistance to proguanil but not to pyrimethamine, suggests that proguanil is still useful even in the face of pyrimethamine resistance. The threat of proguanil resistance is however real due to high prevalence of the triple mutant pfdhfr haplotype.
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Affiliation(s)
- I G Enato
- Institute of Child Health, University of Benin, Benin City, Edo State, Nigeria
- Edo State University, Uzairue, Edo State, Nigeria
| | - A E Sadoh
- Institute of Child Health, University of Benin, Benin City, Edo State, Nigeria
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
| | - O M Ibadin
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
- Department of Child Health, University of Benin, Benin City, Edo State, Nigeria
| | - M E Odunvbun
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
- Department of Child Health, University of Benin, Benin City, Edo State, Nigeria
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9
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Han N, Hwang W, Tzelepis K, Schmerer P, Yankova E, MacMahon M, Lei W, M Katritsis N, Liu A, Felgenhauer U, Schuldt A, Harris R, Chapman K, McCaughan F, Weber F, Kouzarides T. Identification of SARS-CoV-2-induced pathways reveals drug repurposing strategies. Sci Adv 2021; 7:eabh3032. [PMID: 34193418 PMCID: PMC8245040 DOI: 10.1126/sciadv.abh3032] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/14/2021] [Indexed: 05/02/2023]
Abstract
The global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) necessitates the rapid development of new therapies against coronavirus disease 2019 (COVID-19) infection. Here, we present the identification of 200 approved drugs, appropriate for repurposing against COVID-19. We constructed a SARS-CoV-2-induced protein network, based on disease signatures defined by COVID-19 multiomics datasets, and cross-examined these pathways against approved drugs. This analysis identified 200 drugs predicted to target SARS-CoV-2-induced pathways, 40 of which are already in COVID-19 clinical trials, testifying to the validity of the approach. Using artificial neural network analysis, we classified these 200 drugs into nine distinct pathways, within two overarching mechanisms of action (MoAs): viral replication (126) and immune response (74). Two drugs (proguanil and sulfasalazine) implicated in viral replication were shown to inhibit replication in cell assays. This unbiased and validated analysis opens new avenues for the rapid repurposing of approved drugs into clinical trials.
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Affiliation(s)
- Namshik Han
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK.
| | - Woochang Hwang
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
| | | | - Patrick Schmerer
- Institute for Virology, FB10-Veterinary Medicine, Justus-Liebig University, Gießen 35392, Germany
| | - Eliza Yankova
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
| | - Méabh MacMahon
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
- Centre for Therapeutics Discovery, LifeArc, Stevenage, UK
| | - Winnie Lei
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Nicholas M Katritsis
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
- Department of Chemical Engineering and Biotechnology, University of Cambridge, Cambridge, UK
| | - Anika Liu
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
- Department of Chemistry, University of Cambridge, Cambridge, UK
- Data and Computational Sciences, GSK, London, UK
| | - Ulrike Felgenhauer
- Institute for Virology, FB10-Veterinary Medicine, Justus-Liebig University, Gießen 35392, Germany
| | - Alison Schuldt
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
| | - Rebecca Harris
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
| | - Kathryn Chapman
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK
| | - Frank McCaughan
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Friedemann Weber
- Institute for Virology, FB10-Veterinary Medicine, Justus-Liebig University, Gießen 35392, Germany
| | - Tony Kouzarides
- Milner Therapeutics Institute, University of Cambridge, Cambridge, UK.
- The Gurdon Institute and Department of Pathology, University of Cambridge, Cambridge, UK
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10
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Abstract
BACKGROUND The World Health Organization (WHO) in 2015 stated atovaquone-proguanil can be used in travellers, and is an option in malaria-endemic areas in combination with artesunate, as an alternative treatment where first-line artemisinin-based combination therapy (ACT) is not available or effective. This review is an update of a Cochrane Review undertaken in 2005. OBJECTIVES To assess the efficacy and safety of atovaquone-proguanil (alone and in combination with artemisinin drugs) versus other antimalarial drugs for treating uncomplicated Plasmodium falciparum malaria in adults and children. SEARCH METHODS The date of the last trial search was 30 January 2020. Search locations for published trials included the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and LILACS. To include recently published and unpublished trials, we also searched ClinicalTrials.gov, the metaRegister of Controlled Trials and the WHO International Clinical Trials Registry Platform Search Portal. SELECTION CRITERIA Randomized controlled trials (RCTs) reporting efficacy and safety data for atovaquone-proguanil or atovaquone-proguanil with a partner drug compared with at least one other antimalarial drug for treating uncomplicated Plasmodium falciparum infection. DATA COLLECTION AND ANALYSIS For this update, two review authors re-extracted data and assessed certainty of evidence. We meta-analyzed data to calculate risk ratios (RRs) with 95% confidence intervals (CI) for treatment failures between comparisons, and for safety outcomes between and across comparisons. Outcome measures include unadjusted treatment failures and polymerase chain reaction (PCR)-adjusted treatment failures. PCR adjustment differentiates new infection from recrudescent infection. MAIN RESULTS Seventeen RCTs met our inclusion criteria providing 4763 adults and children from Africa, South-America, and South-East Asia. Eight trials reported PCR-adjusted data to distinguish between new and recrudescent infection during the follow-up period. In this abstract, we report only the comparisons against the three WHO-recommended antimalarials which were included within these trials. There were two comparisons with artemether-lumefantrine, one trial from 2008 in Ethiopia with 60 participants had two failures with atovaquone-proguanil compared to none with artemether-lumefantrine (PCR-adjusted treatment failures at day 28). A second trial from 2012 in Colombia with 208 participants had one failure in each arm (PCR-adjusted treatment failures at day 42). There was only one comparison with artesunate-amodiaquine from a 2014 trial conducted in Cameroon. There were six failures with atovaquone-proguanil at day 28 and two with artesunate-amodiaquine (PCR-adjusted treatment failures at day 28: 9.4% with atovaquone-proguanil compared to 2.9% with artesunate-amodiaquine; RR 3.19, 95% CI 0.67 to 15.22; 1 RCT, 132 participants; low-certainty evidence), although there was a similar number of PCR-unadjusted treatment failures (9 (14.1%) with atovaquone-proguanil and 8 (11.8%) with artesunate-amodiaquine; RR 1.20, 95% CI 0.49 to 2.91; 1 RCT, 132 participants; low-certainty evidence). There were two comparisons with artesunate-mefloquine from a 2012 trial in Colombia and a 2002 trial in Thailand where there are high levels of multi-resistant malaria. There were similar numbers of PCR-adjusted treatment failures between groups at day 42 (2.7% with atovaquone-proguanil compared to 2.4% with artesunate-mefloquine; RR 1.15, 95% CI 0.57 to 2.34; 2 RCTs, 1168 participants; high-certainty evidence). There were also similar PCR-unadjusted treatment failures between groups (5.3% with atovaquone-proguanil compared to 6.6% with artesunate-mefloquine; RR 0.8, 95% CI 0.5 to 1.3; 1 RCT, 1063 participants; low-certainty evidence). When atovaquone-proguanil was combined with artesunate, there were fewer treatment failures with and without PCR-adjustment at day 28 (PCR-adjusted treatment failures at day 28: 2.16% with atovaquone-proguanil compared to no failures with artesunate-atovaquone-proguanil; RR 5.14, 95% CI 0.61 to 43.52; 2 RCTs, 375 participants, low-certainty evidence) and day 42 (PCR-adjusted treatment failures at day 42: 3.82% with atovaquone-proguanil compared to 2.05% with artesunate-atovaquone-proguanil (RR 1.84, 95% CI 0.95 to 3.56; 2 RCTs, 1258 participants, moderate-certainty evidence). In the 2002 trial in Thailand, there were fewer treatment failures in the artesunate-atovaquone-proguanil group compared to the atovaquone-proguanil group at day 42 with PCR-adjustment. Whilst there were some small differences in which adverse events were more frequent in the atovaquone-proguanil groups compared to comparator drugs, there were no recurrent associations to suggest that atovaquone-proguanil is strongly associated with any specific adverse event. AUTHORS' CONCLUSIONS Atovaquone-proguanil was effective against uncomplicated P falciparum malaria, although in some instances treatment failure rates were between 5% and 10%. The addition of artesunate to atovaquone-proguanil may reduce treatment failure rates. Artesunate-atovaquone-proguanil and the development of parasite resistance may represent an area for further research.
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Affiliation(s)
- Andrew Blanshard
- Department of Medicine, Norfolk and Norwich University Hospital, Norwich, UK
| | - Paul Hine
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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11
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Abstract
Pregnant travelers face numerous risks, notably increased susceptibility to or severity of multiple infections, including malaria. Because pregnant women residing in areas non-endemic for malaria are unlikely to have protective immunity, travel to endemic areas poses risk of severe illness and pregnancy complications, such as low birthweight and fetal loss. If travel to malaria-endemic areas cannot be avoided, preventive measures are critical. However, malaria chemoprophylaxis in pregnancy can be challenging, since commonly used regimens have varying levels of safety data and national guidelines differ. Furthermore, although chloroquine and mefloquine have wide acceptance for use in pregnancy, regional malaria resistance and non-pregnancy contraindications limit their use. Mosquito repellents, including N,N-diethyl-m-toluamide (DEET) and permethrin treatment of clothing, are considered safe in pregnancy and important to prevent malaria as well as other arthropod-borne infections such as Zika virus infection. Pregnant travelers at risk for malaria exposure should be advised to seek medical attention immediately if any symptoms of illness, particularly fever, develop.
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Affiliation(s)
- Kimberly L. McKinney
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA
| | - Henry M. Wu
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathrine R. Tan
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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12
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Arsuaga M, González LM, Padial ES, Dinkessa AW, Sevilla E, Trigo E, Puente S, Gray J, Montero E. Misdiagnosis of Babesiosis as Malaria, Equatorial Guinea, 2014. Emerg Infect Dis 2019; 24:1588-1589. [PMID: 30016247 PMCID: PMC6056097 DOI: 10.3201/eid2408.180180] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report a case of babesiosis, caused by Babesia microti, in a missionary who worked in Equatorial Guinea but also visited rural Spain. The initial diagnosis, based on clinical features and microscopy, was malaria. The patient’s recovery was delayed until she received appropriate treatment for babesiosis.
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13
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Abstract
Pretravel consultation is important and effective in preventing the spread of malaria. Travelers to high-risk malaria-endemic areas should receive antimalarial advice: a combination of mosquito avoidance measures and chemoprophylaxis. Malaria prevention can be complex owing to the individual characteristics of the traveler, travel destination, duration of stay, and type of travel. Health care providers need to obtain a complete travel history on all returned travelers with clinical infectious features and with a history of travel or migration from malaria-endemic areas. Considering the diagnosis of malaria in febrile travelers with risk factors increases the likelihood of a timely diagnosis and treatment.
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14
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Kaman A, Tanır G, Akkaya B, Bayhan Gİ, Gayretli Aydın ZG, Aydın Teke T. A Case of Recrudescence Plasmodium falciparum Malaria Treated with Atovaquone-Proguanil. Turkiye Parazitol Derg 2018; 42:233-236. [PMID: 30072357 DOI: 10.5152/tpd.2018.5818] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Malaria is a potentially life-threatening disease caused by infection with the Plasmodium protozoa transmitted by an infective female Anopheles mosquito. Despite successful control programs in many countries, malaria remains to be a major disease burden worldwide, with approximately 584,000 deaths annually. The incidence of the disease and responsible species may differ due to increased human movements between countries. Plasmodium falciparum infection carries a poor prognosis with a high mortality if untreated, but it has an excellent prognosis if diagnosed early and treated appropriately. In the present study, we described a patient diagnosed with falciparum malaria and treated with atovaquone-proguanil who had a history of traveling to Uganda.
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Affiliation(s)
- Ayşe Kaman
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Kliniği, Ankara, Türkiye
| | - Gönül Tanır
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Kliniği, Ankara, Türkiye
| | - Bilge Akkaya
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Kliniği, Ankara, Türkiye
| | - Gülsüm İclal Bayhan
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Kliniği, Ankara, Türkiye
| | - Zeynep Gökçe Gayretli Aydın
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Kliniği, Ankara, Türkiye
| | - Türkan Aydın Teke
- Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Kliniği, Ankara, Türkiye
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15
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Abstract
BACKGROUND Mefloquine is one of four antimalarial agents commonly recommended for preventing malaria in travellers to malaria-endemic areas. Despite its high efficacy, there is controversy about its psychological side effects. OBJECTIVES To summarize the efficacy and safety of mefloquine used as prophylaxis for malaria in travellers. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published on the Cochrane Library; MEDLINE; Embase (OVID); TOXLINE (https://toxnet.nlm.nih.gov/newtoxnet/toxline.htm); and LILACS. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; http://www.who.int/ictrp/en/) and ClinicalTrials.gov (https://clinicaltrials.gov/ct2/home) for trials in progress, using 'mefloquine', 'Lariam', and 'malaria' as search terms. The search date was 22 June 2017. SELECTION CRITERIA We included randomized controlled trials (for efficacy and safety) and non-randomized cohort studies (for safety). We compared prophylactic mefloquine with placebo, no treatment, or an alternative recommended antimalarial agent. Our study populations included all adults and children, including pregnant women. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility and risk of bias of trials, extracted and analysed data. We compared dichotomous outcomes using risk ratios (RR) with 95% confidence intervals (CI). Prespecified adverse outcomes are included in 'Summary of findings' tables, with the best available estimate of the absolute frequency of each outcome in short-term international travellers. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 20 RCTs (11,470 participants); 35 cohort studies (198,493 participants); and four large retrospective analyses of health records (800,652 participants). Nine RCTs explicitly excluded participants with a psychiatric history, and 25 cohort studies stated that the choice of antimalarial agent was based on medical history and personal preference. Most RCTs and cohort studies collected data on self-reported or clinician-assessed symptoms, rather than formal medical diagnoses. Mefloquine efficacyOf 12 trials comparing mefloquine and placebo, none were performed in short-term international travellers, and most populations had a degree of immunity to malaria. The percentage of people developing a malaria episode in the control arm varied from 1% to 82% (median 22%) and 0% to 13% in the mefloquine group (median 1%).In four RCTs that directly compared mefloquine, atovaquone-proguanil and doxycycline in non-immune, short-term international travellers, only one clinical case of malaria occurred (4 trials, 1822 participants). Mefloquine safety versus atovaquone-proguanil Participants receiving mefloquine were more likely to discontinue their medication due to adverse effects than atovaquone-proguanil users (RR 2.86, 95% CI 1.53 to 5.31; 3 RCTs, 1438 participants; high-certainty evidence). There were few serious adverse effects reported with mefloquine (15/2651 travellers) and none with atovaquone-proguanil (940 travellers).One RCT and six cohort studies reported on our prespecified adverse effects. In the RCT with short-term travellers, mefloquine users were more likely to report abnormal dreams (RR 2.04, 95% CI 1.37 to 3.04, moderate-certainty evidence), insomnia (RR 4.42, 95% CI 2.56 to 7.64, moderate-certainty evidence), anxiety (RR 6.12, 95% CI 1.82 to 20.66, moderate-certainty evidence), and depressed mood during travel (RR 5.78, 95% CI 1.71 to 19.61, moderate-certainty evidence). The cohort studies in longer-term travellers were consistent with this finding but most had larger effect sizes. Mefloquine users were also more likely to report nausea (high-certainty evidence) and dizziness (high-certainty evidence).Based on the available evidence, our best estimates of absolute effect sizes for mefloquine versus atovaquone-proguanil are 6% versus 2% for discontinuation of the drug, 13% versus 3% for insomnia, 14% versus 7% for abnormal dreams, 6% versus 1% for anxiety, and 6% versus 1% for depressed mood. Mefloquine safety versus doxycyclineNo difference was found in numbers of serious adverse effects with mefloquine and doxycycline (low-certainty evidence) or numbers of discontinuations due to adverse effects (RR 1.08, 95% CI 0.41 to 2.87; 4 RCTs, 763 participants; low-certainty evidence).Six cohort studies in longer-term occupational travellers reported our prespecified adverse effects; one RCT in military personnel and one cohort study in short-term travellers reported adverse events. Mefloquine users were more likely to report abnormal dreams (RR 10.49, 95% CI 3.79 to 29.10; 4 cohort studies, 2588 participants, very low-certainty evidence), insomnia (RR 4.14, 95% CI 1.19 to 14.44; 4 cohort studies, 3212 participants, very low-certainty evidence), anxiety (RR 18.04, 95% CI 9.32 to 34.93; 3 cohort studies, 2559 participants, very low-certainty evidence), and depressed mood (RR 11.43, 95% CI 5.21 to 25.07; 2 cohort studies, 2445 participants, very low-certainty evidence). The findings of the single cohort study reporting adverse events in short-term international travellers were consistent with this finding but the single RCT in military personnel did not demonstrate a difference between groups in frequencies of abnormal dreams or insomnia.Mefloquine users were less likely to report dyspepsia (RR 0.26, 95% CI 0.09 to 0.74; 5 cohort studies, 5104 participants, low certainty-evidence), photosensitivity (RR 0.08, 95% CI 0.05 to 0.11; 2 cohort studies, 1875 participants, very low-certainty evidence), vomiting (RR 0.18, 95% CI 0.12 to 0.27; 4 cohort studies, 5071 participants, very low-certainty evidence), and vaginal thrush (RR 0.10, 95% CI 0.06 to 0.16; 1 cohort study, 1761 participants, very low-certainty evidence).Based on the available evidence, our best estimates of absolute effect for mefloquine versus doxycyline were: 2% versus 2% for discontinuation, 12% versus 3% for insomnia, 31% versus 3% for abnormal dreams, 18% versus 1% for anxiety, 11% versus 1% for depressed mood, 4% versus 14% for dyspepsia, 2% versus 19% for photosensitivity, 1% versus 5% for vomiting, and 2% versus 16% for vaginal thrush.Additional analyses, including comparisons of mefloquine with chloroquine, added no new information. Subgroup analysis by study design, duration of travel, and military versus non-military participants, provided no conclusive findings. AUTHORS' CONCLUSIONS The absolute risk of malaria during short-term travel appears low with all three established antimalarial agents (mefloquine, doxycycline, and atovaquone-proguanil).The choice of antimalarial agent depends on how individual travellers assess the importance of specific adverse effects, pill burden, and cost. Some travellers will prefer mefloquine for its once-weekly regimen, but this should be balanced against the increased frequency of abnormal dreams, anxiety, insomnia, and depressed mood.
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Affiliation(s)
| | - Nicola Maayan
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Rachel Saunders
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Cheryl Pace
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
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16
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Tan KR, Henderson SJ, Williamson J, Ferguson RW, Wilkinson TM, Jung P, Arguin PM. Long term health outcomes among Returned Peace Corps Volunteers after malaria prophylaxis, 1995-2014. Travel Med Infect Dis 2017; 17:50-55. [PMID: 28487213 PMCID: PMC10956545 DOI: 10.1016/j.tmaid.2017.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 04/11/2017] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND A primary reason for non-adherence to malaria chemoprophylaxis is fear of latent side effects. We examined latent effects of malaria chemoprophylaxis among Returned Peace Corps Volunteers (RPCVs). METHODS During July 18-September 16, 2016, RPCVs who served during 1995-2014 with an e-mail address in Peace Corps' RPCV database were invited to take an internet-based survey on malaria prophylaxis and medical diagnoses. "Good adherence" meant taking prophylaxis "as prescribed" or "most of the time." Prevalence of diseases diagnosed after Peace Corps service was compared between users and nonusers of each antimalarial using log-binomial regression. RESULTS Of 8931 participants (11% response rate), 5055 (57%) took chemoprophylaxis. Initial chemoprophylaxis was mefloquine 59%, chloroquine 13%, doxycycline 16%, atovaquone-proguanil 4%, and "other" 8%. Sixty percent reported good adherence. Mefloquine users had the best adherence (67% good adherence). Prevalences of most diseases were similar between exposed and unexposed groups. Certain psychiatric diagnoses were slightly more likely among mefloquine users (PR 1.14, 95% CI [1.04-1.25], P = 0.0048). When excluding those with prior psychiatric illness, there were no differences in psychiatric diagnosis rates. CONCLUSION Malaria chemoprophylaxis use by Peace Corps Volunteers is safe. Avoiding mefloquine use in those with prior psychiatric illness can reduce psychiatric side effects.
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Affiliation(s)
- Kathrine R Tan
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - John Williamson
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | - Paul M Arguin
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
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17
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Matthews H, Deakin J, Rajab M, Idris-Usman M, Nirmalan NJ. Investigating antimalarial drug interactions of emetine dihydrochloride hydrate using CalcuSyn-based interactivity calculations. PLoS One 2017; 12:e0173303. [PMID: 28257497 PMCID: PMC5336292 DOI: 10.1371/journal.pone.0173303] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 09/22/2016] [Accepted: 02/17/2017] [Indexed: 11/18/2022] Open
Abstract
The widespread introduction of artemisinin-based combination therapy has contributed to recent reductions in malaria mortality. Combination therapies have a range of advantages, including synergism, toxicity reduction, and delaying the onset of resistance acquisition. Unfortunately, antimalarial combination therapy is limited by the depleting repertoire of effective drugs with distinct target pathways. To fast-track antimalarial drug discovery, we have previously employed drug-repositioning to identify the anti-amoebic drug, emetine dihydrochloride hydrate, as a potential candidate for repositioned use against malaria. Despite its 1000-fold increase in in vitro antimalarial potency (ED50 47 nM) compared with its anti-amoebic potency (ED50 26–32 uM), practical use of the compound has been limited by dose-dependent toxicity (emesis and cardiotoxicity). Identification of a synergistic partner drug would present an opportunity for dose-reduction, thus increasing the therapeutic window. The lack of reliable and standardised methodology to enable the in vitro definition of synergistic potential for antimalarials is a major drawback. Here we use isobologram and combination-index data generated by CalcuSyn software analyses (Biosoft v2.1) to define drug interactivity in an objective, automated manner. The method, based on the median effect principle proposed by Chou and Talalay, was initially validated for antimalarial application using the known synergistic combination (atovaquone-proguanil). The combination was used to further understand the relationship between SYBR Green viability and cytocidal versus cytostatic effects of drugs at higher levels of inhibition. We report here the use of the optimised Chou Talalay method to define synergistic antimalarial drug interactivity between emetine dihydrochloride hydrate and atovaquone. The novel findings present a potential route to harness the nanomolar antimalarial efficacy of this affordable natural product.
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Affiliation(s)
- Holly Matthews
- Environment and Life sciences, University of Salford, Greater Manchester, United Kingdom
| | - Jon Deakin
- Environment and Life sciences, University of Salford, Greater Manchester, United Kingdom
| | - May Rajab
- Environment and Life sciences, University of Salford, Greater Manchester, United Kingdom
| | - Maryam Idris-Usman
- Environment and Life sciences, University of Salford, Greater Manchester, United Kingdom
| | - Niroshini J. Nirmalan
- Environment and Life sciences, University of Salford, Greater Manchester, United Kingdom
- * E-mail:
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18
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Abstract
We present a case of a 52-year-old woman of Ghanaian origin who developed Plasmodium falciparum malaria 4 years after leaving Africa. She had not returned to an endemic area since. We hypothesize several possible scenarios to explain this infection, of which we believe recrudescence of P. falciparum is the most plausible. This occurred most likely as a consequence of waning immunity several years after leaving a high-transmission area. She recovered after a 3-day treatment with atovaquone/proguanil.
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Affiliation(s)
- B Vantomme
- a Department of Internal Medicine , Ghent University Hospital , Belgium
| | - J Van Acker
- b Department of Clinical Biology , St. Lucas General Hospital , Ghent , Belgium
| | - S Rogge
- c Department of Gastroenterology , St. Lucas General Hospital , Ghent , Belgium
| | - D Ommeslag
- d Department of Infectious Diseases , St. Lucas General Hospital , Ghent , Belgium
- e Department of Pneumology , St. Lucas General Hospital , Ghent , Belgium
| | - J Donck
- f Department of Nephrology , St. Lucas General Hospital , Ghent , Belgium
| | - S Callens
- g Department of Infectious Diseases , Ghent University Hospital , Belgium
- h Department of Infectious Diseases , St. Lucas General Hospital , Belgium
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19
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20
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Poirot E, Vittinghoff E, Ishengoma D, Alifrangis M, Carneiro I, Hashim R, Baraka V, Mosha J, Gesase S, Chandramohan D, Gosling R. Risks of Hemolysis in Glucose-6-Phosphate Dehydrogenase Deficient Infants Exposed to Chlorproguanil-Dapsone, Mefloquine and Sulfadoxine-Pyrimethamine as Part of Intermittent Presumptive Treatment of Malaria in Infants. PLoS One 2015; 10:e0142414. [PMID: 26599634 PMCID: PMC4658078 DOI: 10.1371/journal.pone.0142414] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 06/18/2015] [Accepted: 10/20/2015] [Indexed: 12/24/2022] Open
Abstract
Background Chlorproguanil-dapsone (CD) has been linked to hemolysis in symptomatic glucose-6-phosphate dehydrogenase deficient (G6PDd) children. Few studies have explored the effects of G6PD status on hemolysis in children treated with Intermittent Preventive Treatment in infants (IPTi) antimalarial regimens. We sought to examine the joint effects of G6PD status and IPTi antimalarial treatment on incidence of hemolysis in asymptomatic children treated with CD, sulfadoxine-pyrimethamine (SP), and mefloquine (MQ). Methods A secondary analysis of data from a double-blind, placebo-controlled trial of IPTi was conducted. Hemoglobin (Hb) measurements were made at IPTi doses, regular follow-up and emergency visits. G6PD genotype was determined at 9 months looking for SNPs for the A- genotype at coding position 202. Multivariable linear and logistic regression models were used to examine hemolysis among children with valid G6PD genotyping results. Hemolysis was defined as the absolute change in Hb or as any post-dose Hb <8 g/dL. These outcomes were assessed using either a single follow-up Hb on day 7 after an IPTi dose or Hb obtained 1 to 14 or 28 days after each IPTi dose. Findings Relative to placebo, CD reduced Hb by approximately 0.5 g/dL at day 7 and within 14 days of an IPTi dose, and by 0.2 g/dL within 28 days. Adjusted declines in the CD group were larger than in the MQ and SP groups. At day 7, homo-/hemizygous genotype was associated with higher odds of Hb <8 g/dL (adjusted odds ratio = 6.7, 95% CI 1.7 to 27.0) and greater absolute reductions in Hb (-0.6 g/dL, 95% CI -1.1 to 0.003). There was no evidence to suggest increased reductions in Hb among homo-/hemizygous children treated with CD compared to placebo, SP or MQ. Conclusions While treatment with CD demonstrated greater reductions in Hb at 7 and 14 days after an IPTi dose compared to both SP and MQ, there was no evidence that G6PD deficiency exacerbated the adverse effects of CD, despite evidence for higher hemolysis risk among G6PDd infants.
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Affiliation(s)
- Eugenie Poirot
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Eric Vittinghoff
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | - Deus Ishengoma
- Tanga Medical Research Centre, National Institute for Medical Research, Tanga, United Republic of Tanzania
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, National University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Ilona Carneiro
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ramadhan Hashim
- Mwanza Interventions Trial Unit, National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Vito Baraka
- Tanga Medical Research Centre, National Institute for Medical Research, Tanga, United Republic of Tanzania
- International Health Unit, Department of Epidemiology, University of Antwerp, Antwerp, Belgium
| | - Jacklin Mosha
- Mwanza Interventions Trial Unit, National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Samwel Gesase
- Tanga Medical Research Centre, National Institute for Medical Research, Tanga, United Republic of Tanzania
| | - Daniel Chandramohan
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roland Gosling
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
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21
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Affiliation(s)
- Frederique A Jacquerioz
- Tropical Medicine, Tulane School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, Louisiana, USA, LA 70112
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Calitri C, Garazzino S, Camilla R, Peruzzi L, Amore A, Tovo PA. "Collateral" effect of artemether in an atypical kidney involvement by Plasmodium falciparum malaria: a case report. J Vector Borne Dis 2014; 51:147-148. [PMID: 24947225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Affiliation(s)
- Carmelina Calitri
- Department of Paediatrics, Infectious Diseases Unit, University of Turin, Regina Margherita Children Hospital, Turin, Italy
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23
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Møller CH, David K. Imported malaria is stable from Africa but declining from Asia. Dan Med J 2014; 61:A4827. [PMID: 24814737] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION In this study, we describe patients with imported malaria seen at the Department of Infectious Diseases (DID), Hvidovre Hospital, Denmark. Our aim was to address possible risk factors for contracting malaria and risk factors for developing complicated malaria. MATERIAL AND METHODS We searched patient databases for all cases of malaria seen at the DID from 1994 to 2012. Various parameters were registered. RESULTS A total of 320 cases were identified. We found a significant 3.39 % decrease in the incidence of cases per year (p = 0.0008). Plasmodium falciparum infection was predominant (n = 217) followed by P. vivax infection (n = 76). 37% of all cases were Africans visiting relatives and friends (VRF). A total of 12 patients had one or more re-lapses of their P. vivax infection. In all, 53 (17%) cases were defined as severe malaria. 36% (n = 112) reported using some type of chemoprophylaxis. 14% (n = 26) of patients traveling to Africa in 1999-2012 reported taking chemoprophylaxis as recommended in the current guidelines. Complicated malaria was significantly associated with failure to take any chemoprophylaxis (p = 0.0317, χ(2)-test). CONCLUSION Imported malaria is decreasing at the DID. The patients who carry the highest risk of imported malaria are ethnic Africans who travel as VRF without using chemoprophylaxis. Recrudescence from P. vivax malaria is a substantial risk. Complicated malaria is associated with failure to take any chemoprophylaxis. It is important that travelers receive expedient advice on the use of efficient chemoprophylaxis to bring down the number of imported malaria cases. FUNDING not relevant. TRIAL REGISTRATION not relevant.
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Stewart LB, Peters W, Robinson BL. The chemotherapy of rodent malaria. LXII. Drug combinations to impede the selection of drug resistance, part 5: rates of development of resistance to some inhibitors of folate metabolism and to artesunate. Annals of Tropical Medicine & Parasitology 2013; 98:763-83. [PMID: 15667710 DOI: 10.1179/136485913x13789813917625] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In recent years infection with chloroquine-resistant Plasmodium falciparum has been combatted with two long-acting antimalarials, pyrimethamine and sulfadoxine, in the combination known as Fansidar that exerts a strong, synergistic action on the asexual stages of the parasite. This second-line regimen, however, is failing increasingly because of the selection of resistant clones in endemic areas, and effective, safe, alternative drugs or drug combinations that are also affordable are urgently needed. Antimalarial drugs with shorter half-lives than those of pyrimethamine or sulfadoxine are likely to be slower to select resistant parasites. In the experiments reported here, the baseline in-vivo responses of rodent malarial parasites to chlorproguanil and proguanil and their active metabolites, chlorcycloguanil and cycloguanil, as well as those to dapsone and artesunate, were explored. In general, the most sensitive parasite to all of these compounds was P. chabaudi. When the drugs were used, individually, to select resistance via the '2%-relapse technique', relatively stable resistance to each was obtained in P. chabaudi as well as in P. berghei and P. yoelii ssp. NS, the last of these being also highly resistant to chloroquine. Of most concern was the rapidity and high level of resistance developed by P. chabaudi to artesunate. The experiments also validated the use of chlorcycloguanil or cycloguanil as surrogates for chlorproguanil or proguanil. Further studies to investigate the possible value of administering chlorproguanil-dapsone, with or without artesunate, are under way and will be reported separately.
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Affiliation(s)
- L B Stewart
- Centre for Tropical Antiprotozoal Chemotherapy, Y Block, Northwick Park Institute for Medical Research, Watford Road, Harrow HA1 3UJ, UK.
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25
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Kondrashin AV, Tumol'skaia NI, Morozova LF. [Malaria alertness in the post-elimination period: clinical and laboratory aspects]. Med Parazitol (Mosk) 2013:11-15. [PMID: 24640124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Early detection of imported cases of malaria and its prompt and efficacious treatment are one of the main tasks of health workers in malaria prevention during the post-elimination period. The diagnosis and treatment of malaria should be developed and standardized to prevent the re-emergence of local transmission from imported cases of malaria. Its diagnosis must be verified by only laboratory tests during the post-elimination period. Keeping in mind the possible rapid conversion of uncomplicated P. falciparum malaria into a several disease, these all cases should be managed in a hospital setting. The healthcare personnel dealing with the treatment of malaria should be aware of its clinical manifestations in non-immune residents and semi-immune immigrants. The main principles of malaria treatment are discussed in respect of age, sex, pregnancy, and different malaria species.
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Berrevoets MAH, Sprong T, Meis JF, Dofferhoff ASM. Plasmodium falciparum malaria recrudescence occurring 2.5 years after leaving an endemic country. Neth J Med 2013; 71:426-428. [PMID: 24127503] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Malaria tropica is almost exclusively diagnosed within two months after returning from an endemic country. We present here a male patient with severe P. falciparum malaria diagnosed 2.5 years after returning from Burkina-Faso. We speculate that our patient was chronically infected with PF malaria for more than 2 years, with an undetectable parasite index and without symptoms. Because of waning immunity clinically overt PF malaria was able to develop. This case illustrates the importance of malaria suspicion as a cause of illness in immigrants from malaria-endemic countries. Even when these immigrants did not travel for a long time, malaria should be considered in patients with typical symptoms.
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Affiliation(s)
- M A H Berrevoets
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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Hoyer S, Nguon S, Kim S, Habib N, Khim N, Sum S, Christophel EM, Bjorge S, Thomson A, Kheng S, Chea N, Yok S, Top S, Ros S, Sophal U, Thompson MM, Mellor S, Ariey F, Witkowski B, Yeang C, Yeung S, Duong S, Newman RD, Menard D. Focused Screening and Treatment (FSAT): a PCR-based strategy to detect malaria parasite carriers and contain drug resistant P. falciparum, Pailin, Cambodia. PLoS One 2012; 7:e45797. [PMID: 23049687 PMCID: PMC3462177 DOI: 10.1371/journal.pone.0045797] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [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: 06/16/2012] [Accepted: 08/24/2012] [Indexed: 11/19/2022] Open
Abstract
Recent studies have shown that Plasmodium falciparum malaria parasites in Pailin province, along the border between Thailand and Cambodia, have become resistant to artemisinin derivatives. To better define the epidemiology of P. falciparum populations and to assess the risk of the possible spread of these parasites outside Pailin, a new epidemiological tool named “Focused Screening and Treatment” (FSAT), based on active molecular detection of asymptomatic parasite carriers was introduced in 2010. Cross-sectional malariometric surveys using PCR were carried out in 20 out of 109 villages in Pailin province. Individuals detected as P. falciparum carriers were treated with atovaquone-proguanil combination plus a single dose of primaquine if the patient was non-G6PD deficient. Interviews were conducted to elicit history of cross-border travel that might contribute to the spread of artemisinin-resistant parasites. After directly observed treatment, patients were followed up and re-examined on day 7 and day 28. Among 6931 individuals screened, prevalence of P. falciparum carriers was less than 1%, of whom 96% were asymptomatic. Only 1.6% of the individuals had a travel history or plans to go outside Cambodia, with none of those tested being positive for P. falciparum. Retrospective analysis, using 2010 routine surveillance data, showed significant differences in the prevalence of asymptomatic carriers discovered by FSAT between villages classified as “high risk” and “low risk” based on malaria incidence data. All positive individuals treated and followed-up until day 28 were cured. No mutant-type allele related to atovaquone resistance was found. FSAT is a potentially useful tool to detect, treat and track clusters of asymptomatic carriers of P. falciparum along with providing valuable epidemiological information regarding cross-border movements of potential malaria parasite carriers and parasite gene flow.
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Affiliation(s)
- Stefan Hoyer
- World Health Organization, Global Malaria Programme, Geneva, Switzerland
- * E-mail: (SH); (DM)
| | - Sokomar Nguon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Saorin Kim
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | | | - Nimol Khim
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Sarorn Sum
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Eva-Maria Christophel
- World Health Organization, Regional Office for the Western Pacific, Manilla, Philippines
| | | | | | - Sim Kheng
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Nguon Chea
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Sovann Yok
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Samphornarann Top
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Seyha Ros
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Uth Sophal
- Malaria Consortium, Phnom Penh, Cambodia
| | | | | | - Frédéric Ariey
- Unité d'Immunologie Moléculaire des Parasites, Institut Pasteur, Paris, France
| | - Benoit Witkowski
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Chhiang Yeang
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Shunmay Yeung
- Malaria Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Socheat Duong
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Robert D. Newman
- World Health Organization, Global Malaria Programme, Geneva, Switzerland
| | - Didier Menard
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
- * E-mail: (SH); (DM)
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Laufer MK, Thesing PC, Dzinjalamala FK, Nyirenda OM, Masonga R, Laurens MB, Stokes-Riner A, Taylor TE, Plowe CV. A longitudinal trial comparing chloroquine as monotherapy or in combination with artesunate, azithromycin or atovaquone-proguanil to treat malaria. PLoS One 2012; 7:e42284. [PMID: 22912697 PMCID: PMC3422316 DOI: 10.1371/journal.pone.0042284] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 07/02/2012] [Indexed: 11/30/2022] Open
Abstract
Background The predominance of chloroquine-susceptible falciparum malaria in Malawi more than a decade after chloroquine's withdrawal permits contemplation of re-introducing chloroquine for targeted uses. We aimed to compare the ability of different partner drugs to preserve chloroquine efficacy and prevent the re-emergence of resistance. Methodology/Principal Findings Children with uncomplicated malaria were enrolled at a government health center in Blantyre, Malawi. Participants were randomized to receive chloroquine alone or combined with artesunate, azithromycin or atovaquone-proguanil for all episodes of uncomplicated malaria for one year. The primary outcome was incidence of clinical malaria. Secondary endpoints included treatment efficacy, and incidence of the chloroquine resistance marker pfcrt T76 and of anemia. Of the 640 children enrolled, 628 were included in the intention-to-treat analysis. Malaria incidence (95% confidence interval) was 0.59 (.46–.74), .61 (.49–.76), .63 (.50–.79) and .68 (.54–.86) episodes/person-year for group randomized to receive chloroquine alone or in combination with artesunate, azithromycin or atovaquone-proguanil respectively and the differences were not statistically significant. Treatment efficacy for first episodes was 100% for chloroquine monotherapy and 97.9% for subsequent episodes of malaria. Similar results were seen in each of the chloroquine combination groups. The incidence of pfcrt T76 in pure form was 0%; mixed infections with both K76 and T76 were found in two out of 911 infections. Young children treated with chloroquine-azithromycin had higher hemoglobin concentrations at the study's end than did those in the chloroquine monotherapy group. Conclusion/Significance Sustained chloroquine efficacy with repeated treatment supports the eventual re-introduction of chloroquine combinations for targeted uses such as intermittent preventive treatment. Trial Registration: ClinicalTrials.gov NCT00379821
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Affiliation(s)
- Miriam K Laufer
- Malaria Group, Howard Hughes Medical Institute/Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
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Bouchaud O, Mühlberger N, Parola P, Calleri G, Matteelli A, Peyerl-Hoffmann G, Méchaï F, Gautret P, Clerinx J, Kremsner PG, Jelinek T, Kaiser A, Beltrame A, Schmid ML, Kern P, Probst M, Bartoloni A, Weinke T, Grobusch MP. Therapy of uncomplicated falciparum malaria in Europe: MALTHER - a prospective observational multicentre study. Malar J 2012; 11:212. [PMID: 22720832 PMCID: PMC3477029 DOI: 10.1186/1475-2875-11-212] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 06/08/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria continues to be amongst the most frequent infectious diseases imported to Europe. Whilst European treatment guidelines are based on data from studies carried out in endemic areas, there is a paucity of original prospective treatment data. The objective was to summarize data on treatments to harmonize and optimize treatment for uncomplicated malaria in Europe. METHODS A prospective observational multicentre study was conducted, assessing tolerance and efficacy of treatment regimens for imported uncomplicated falciparum malaria in adults amongst European centres of tropical and travel medicine. RESULTS Between December 2003 and 2009, 504 patients were included in 16 centres from five European countries. Eighteen treatment regimens were reported, the top three being atovaquone-proguanil, mefloquine, and artemether-lumefantrine. Treatments significantly differed with respect to the occurrence of treatment changes (p = 0.005) and adverse events (p = 0.001), parasite and fever clearance times (p < 0.001), and hospitalization rates (p = 0.0066) and durations (p = 0.001). Four recrudescences and two progressions to severe disease were observed. Compared to other regimens, quinine alone was associated with more frequent switches to second line treatment, more adverse events and longer inpatient stays. Parasite and fever clearance times were shortest with artemether-mefloquine combination treatment. Vomiting was the most frequent cause of treatment change, occurring in 5.5% of all patients but 9% of the atovaquone-proguanil group. CONCLUSIONS This study highlights the heterogeneity of standards of care within Europe. A consensus discussion at European level is desirable to foster a standardized management of imported falciparum malaria.
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Affiliation(s)
- Olivier Bouchaud
- Infectious and Tropical Diseases Department, Hôpital Avicenne-APHP and Université Paris 13, Bobigny, France
| | - Nikolai Mühlberger
- Department of Public Health and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Philippe Parola
- Infectious and Tropical Medicine Unit, North University Hospital, 13015, Marseille, France
| | - Guido Calleri
- Divisione Malattie Infettive e Tropicali, Ospedale “Amedeo di Savoia”, Torino, Italy
| | - Alberto Matteelli
- Institute of Infectious and Tropical Diseases, University Hospital, Brescia, Italy
| | - Gabriele Peyerl-Hoffmann
- Centre for Infectious Diseases and Travel Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Frédéric Méchaï
- Infectious and Tropical Diseases Department, Hôpital Avicenne-APHP and Université Paris 13, Bobigny, France
| | - Philippe Gautret
- Infectious and Tropical Medicine Unit, North University Hospital, 13015, Marseille, France
| | - Jan Clerinx
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Peter G Kremsner
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Tomas Jelinek
- Berlin Centre for Travel and Tropical Medicine, Berlin, Germany
| | - Annette Kaiser
- Institute of Medical Microbiology and Parasitology, University of Bonn, Bonn, Germany
| | - Anna Beltrame
- Clinica de Malattie Infettive, AOU di Udine, Udine, Italy
| | - Matthias L Schmid
- Department of Infection & Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Peter Kern
- Comprehensive Infectious Diseases Center, University Hospitals, Ulm, Germany
| | - Meike Probst
- Medizinische Klinik m. S. Infektiologie, Charité University Hospital, Berlin, Germany
| | - Alessandro Bartoloni
- Infectious and Tropical Diseases Unit, AOU Careggi, and Department of Critical Care Medicine and Surgery, University of Florence, Florence, Italy
| | - Thomas Weinke
- Department of Gastroenterology and Infectious Diseases, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Martin P Grobusch
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Centre for Tropical and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam Medical Centre, University of Amsterdam, Meibergdreef 9, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
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Irvine MH, Einarson A, Bozzo P. Prophylactic use of antimalarials during pregnancy. Can Fam Physician 2011; 57:1279-1281. [PMID: 22084457 PMCID: PMC3215604] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
QUESTION Some of my pregnant patients wish to travel to malaria-endemic regions. Are there medications that can be used safely during pregnancy for malaria prophylaxis? ANSWER Pregnant women should avoid travel to malaria-endemic areas if possible. However, if travel cannot be avoided, measures to prevent mosquito bites, along with an effective chemoprophylaxis regimen, should be implemented. Chloroquine or hydroxychloroquine are considered safe to use in all trimesters of pregnancy. Mefloquine is the agent of choice for chloroquine-resistant areas, and evidence suggests it is not associated with an increased risk to the fetus. Although the atovaquone-proguanil drug combination is not currently recommended for use during pregnancy, limited data suggest that it is not harmful to the fetus. Doxycycline and primaquine are not recommended during pregnancy.
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Abstract
BACKGROUND To prevent the development of drug resistance, the World Health Organization (WHO) recommends treating malaria with combination therapy. Azithromycin, an antibiotic with antimalarial properties, may be a useful additional option for antimalarial therapy. OBJECTIVES To compare the use of azithromycin alone or in combination with other antimalarial drugs with the use of alternative antimalarial drugs for treating uncomplicated malaria caused by Plasmodium falciparum or Plasmodium vivax. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (August 2010); CENTRAL (The Cochrane Library Issue 3, 2010); MEDLINE (1966 to August 2010); EMBASE (1974 to August 2010); LILACS (August 2010); the metaRegister of Controlled Trials (mRCT, August 2010); conference proceedings; and reference lists. We also contacted researchers and a pharmaceutical company. SELECTION CRITERIA Randomized controlled trials comparing azithromycin, either alone or combined with another antimalarial drug, with another antimalarial drug used alone or combined with another antimalarial drug, or with azithromycin combined with another antimalarial drug if different combinations or doses of azithromycin were used. The primary outcome was treatment failure by day 28, defined as parasitological or clinical evidence of treatment failure between the start of treatment and day 28. Secondary outcomes included treatment failure by day 28 corrected for new infections confirmed by polymerase chain reaction (PCR), fever and parasite clearance time, and adverse events. DATA COLLECTION AND ANALYSIS Two people independently applied the inclusion criteria, extracted data and assessed methodological quality. We used risk ratio (RR) and 95% confidence intervals (CI). MAIN RESULTS Fifteen trials met the inclusion criteria (2284 participants, 69% males, 16% children). They were conducted in disparate malaria endemic areas, with the earlier studies conducted in Thailand (five) and India (two), and the more recent studies (eight) spread across three continents (South America, Africa, Asia). The 15 studies involved 41 treatment arms, 12 different drugs, and 28 different treatment regimens. Two studies examined P. vivax.Three-day azithromycin (AZ) monotherapy did not perform well for P. vivax or P. falciparum (Thailand: P. vivax failure rate 0.5 g daily, 56%, 95% CI 31 to 78. India: P. vivax failure rate 1 g daily,12%, 95% CI 7 to 21; P. falciparum failure rate 1 g daily, 64%, 95% CI 36 to 86.) A 1 g azithromycin and 0.6 g chloroquine combination daily for three days for uncomplicated P. falciparum infections was associated with increased treatment failure in India and Indonesia compared with the combination of sulphadoxine-pyrimethamine and chloroquine (pooled RR 2.66, 95% CI 1.25 to 5.67), and compared with the combination atovaquone-proguanil in a multicentre trial in Columbia and Surinam (RR 24.72, 95% CI 6.16 to 99.20). No increased risk of treatment failure was seen in two studies in Africa with mefloquine as the comparator drug (pooled RR 2.02, 95% CI 0.51 to 7.96, P = 0.3); the pooled RR for PCR-corrected data for the combination versus mefloquine was 1.01, 95% CI 0.18 to 5.84 (P = 1.0). An increased treatment failure risk was seen when comparing azithromycin in a dose of 1.2 to 1.5 mg in combination with artesunate (200 mg per day for three days) with artemether-lumefantrine (pooled RR 3.08, 95% CI 2.09 to 4.55; PCR-corrected pooled RR 3.63, 95% CI 2.02 to 6.52).Serious adverse events and treatment discontinuation were similar across treatment arms. More adverse events were reported when comparing the 1 g azithromycin/ 0.6 g chloroquine combination with mefloquine (pooled RR 1.20, 95% CI 1.06 to 1.36) or atovaquone-proguanil (RR 1.41, 95% CI 1.09 to1.83). AUTHORS' CONCLUSIONS Currently, there is no evidence for the superiority or equivalence of azithromycin monotherapy or combination therapy for the treatment of P. falciparum or P. vivax compared with other antimalarials or with the current first-line antimalarial combinations. The available evidence suggests that azithromycin is a weak antimalarial with some appealing safety characteristics. Unless the ongoing dose, formulation and product optimisation process results in a universally efficacious product, or a specific niche application is identified that is complementary to the current scala of more efficacious antimalarial combinations, azithromycin's future for the treatment of malaria does not look promising.
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Affiliation(s)
- Anna M van Eijk
- Liverpool School of Tropical MedicineChild & Reproductive Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Dianne J Terlouw
- Liverpool School of Tropical MedicineChild & Reproductive Health GroupPembroke PlaceLiverpoolUKL3 5QA
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Cairns M, Gosling R, Carneiro I, Gesase S, Mosha JF, Hashim R, Kaur H, Lemnge M, Mosha FW, Greenwood B, Chandramohan D. Duration of protection against clinical malaria provided by three regimens of intermittent preventive treatment in Tanzanian infants. PLoS One 2010; 5:e9467. [PMID: 20209126 PMCID: PMC2830887 DOI: 10.1371/journal.pone.0009467] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 01/29/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in infants (IPTi) is a new malaria control tool. However, it is uncertain whether IPTi works mainly through chemoprophylaxis or treatment of existing infections. Understanding the mechanism is essential for development of replacements for sulfadoxine-pyrimethamine (SP) where it is no longer effective. This study investigated how protection against malaria given by SP, chlorproguanil-dapsone (CD) and mefloquine (MQ), varied with time since administration of IPTi. METHODS AND FINDINGS A secondary analysis of data from a randomised, placebo-controlled trial in an area of high antifolate resistance in Tanzania was conducted. IPTi using SP, CD, MQ or placebo was given to 1280 infants at 2, 3 and 9 months of age. Poisson regression with random effects to adjust for potential clustering of malaria episodes within children was used to calculate incidence rate ratios for clinical malaria in defined time strata following IPTi. The short-acting antimalarial CD gave no protection against clinical malaria, whereas long-acting MQ gave two months of substantial protection (protective efficacy (PE) 73.1% (95% CI: 23.9, 90.5) and 73.3% (95% CI: 0, 92.9) in the first and second month respectively). SP gave some protection in the first month after treatment (PE 64.5% (95% CI: 10.6, 85.9)) although it did not reduce the incidence of malaria up to 12 months of age. There was no evidence of either long-term protection or increased risk of malaria for any of the regimens. CONCLUSION Post-treatment chemoprophylaxis appears to be the main mechanism by which IPTi protects children against malaria. Long-acting antimalarials are therefore likely to be the most effective drugs for IPTi, but as monotherapies could be vulnerable to development of drug resistance. Due to concerns about tolerability, the mefloquine formulation used in this study is not suitable for IPTi. Further investigation of combinations of long-acting antimalarials for IPTi is needed. TRIAL REGISTRATION Clinicaltrials.gov NCT00158574.
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Affiliation(s)
- Matthew Cairns
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
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Gosling RD, Gesase S, Mosha JF, Carneiro I, Hashim R, Lemnge M, Mosha FW, Greenwood B, Chandramohan D. Protective efficacy and safety of three antimalarial regimens for intermittent preventive treatment for malaria in infants: a randomised, double-blind, placebo-controlled trial. Lancet 2009; 374:1521-32. [PMID: 19765815 DOI: 10.1016/s0140-6736(09)60997-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Administration of sulfadoxine-pyrimethamine at times of vaccination-intermittent preventive treatment in infants (IPTi)-is a promising strategy to prevent malaria. However, rising resistance to this combination is a concern. We investigated a shortacting and longacting antimalarial drug as alternative regimens for IPTi. METHODS We undertook a double-blind, placebo-controlled trial of IPTi in an area of high resistance to sulfadoxine-pyrimethamine at sites of moderate (n=1280 infants enrolled) and low (n=1139) intensity of malaria transmission in Tanzania. Infants aged 8-16 weeks were randomly assigned in blocks of 16 to sulfadoxine (250 mg) plus pyrimethamine (12.5 mg; n=319 in moderate-transmission and 283 in low-transmission sites), chlorproguanil (15 mg) plus dapsone (18.75 mg; n=317 and 285), mefloquine (125 mg; n=320 and 284), or placebo (n=320 and 284), given at the second and third immunisations for diphtheria, pertussis, and tetanus, and for measles. Research team and child were masked to treatment. Recruitment was stopped early at the low-transmission site because of low malaria incidence. The primary endpoint was protective efficacy against all episodes of clinical malaria at 2-11 months of age. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00158574. FINDINGS All randomly assigned infants were analysed. At the moderate-transmission site, mefloquine had a protective efficacy of 38.1% (95% CI 11.8-56.5, p=0.008) against clinical malaria in infants aged 2-11 months, but neither sulfadoxine-pyrimethamine (-6.7%, -45.9 to 22.0) nor chlorproguanil-dapsone (10.8%, -24.6 to 36.1) had a protective effect. No regimen had any protective efficacy against anaemia or hospital admission. Mefloquine caused vomiting in 141 of 1731 (8%) doses given on day 1 (odds ratio vs placebo 5.50, 95% CI 3.56-8.46). More infants died in the chlorproguanil-dapsone and mefloquine groups (18 and 15, respectively) than in the sulfadoxine-pyrimethamine or placebo groups (eight deaths per group; p=0.05 for difference between chlorproguanil-dapsone and placebo). INTERPRETATION IPTi with a longacting, efficacious drug such as mefloquine can reduce episodes of malaria in infants in a moderate-transmission setting. IPTi with sulfadoxine-pyrimethamine has no benefit in areas of very high resistance to this combination. The appropriateness of IPTi should be measured by the expected incidence of malaria and the efficacy, tolerability, and safety of the drug. FUNDING IPTi Consortium and the Gates Malaria Partnership.
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Affiliation(s)
- Roly D Gosling
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Abstract
BACKGROUND Malaria infects 10,000 to 30,000 international travellers each year. It can be prevented through anti-mosquito measures and drug prophylaxis. However, antimalaria drugs have adverse effects which are sometimes serious. OBJECTIVES To compare the effects of currently used antimalaria drugs when given as prophylaxis to non-immune adult and child travellers who are travelling to regions with Plasmodium falciparum resistance to chloroquine. Specifically, to assess the efficacy, safety, and tolerability of atovaquone-proguanil, doxycycline, and mefloquine compared to each other, and also when compared to chloroquine-proguanil and to primaquine. SEARCH STRATEGY In August 2009 we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 4), MEDLINE, EMBASE, LILACS, BIOSIS, mRCT, and reference lists. We handsearched conference proceedings and one specialist journal, and contacted researchers and drug companies. We searched PubMed for drug-related deaths. SELECTION CRITERIA Randomized and quasi-randomized controlled trials of any antimalaria drug regimen currently used by non-immune international travellers. DATA COLLECTION AND ANALYSIS We independently extracted data and assessed eligibility and risk of bias using a standardized data collection form. We resolved any disagreement through discussion. We combined dichotomous outcomes using risk ratio (RR) and continuous data using mean difference (MD), presenting both with 95% confidence intervals (CI). MAIN RESULTS Eight trials (4240 participants) met the inclusion criteria. Evidence on comparative efficacy from head-to-head comparisons was limited. Atovaquone-proguanil compared to doxycycline had similar adverse events reported. Compared to mefloquine, atovaquone-proguanil users had fewer reports of any adverse effect (RR 0.72, 95% CI 0.6 to 0.85), gastrointestinal adverse effects (RR 0.54, 95% CI 0.42 to 0.7), neuropsychiatric adverse events (RR 0.86, 95% CI 0.75 to 0.99), and neuropsychiatric adverse effects (RR 0.49, 95% CI 0.38 to 0.63), besides a better total mood disturbance score (MD -7.20, 95% CI -10.79 to -3.61). Similarly, doxycycline users had fewer reported neuropsychiatric events than mefloquine users (RR 0.84, 95% CI 0.73 to 0.96). We also examined these three regimens against chloroquine-proguanil; this latter regimen had more reports of any adverse effect (RR 0.84, 95% CI 0.73 to 0.96) and of gastrointestinal adverse effects (RR 0.71, 95% CI 0.6 to 0.85). AUTHORS' CONCLUSIONS Atovaquone-proguanil and doxycycline are the best tolerated regimens, and mefloquine is associated with adverse neuropsychiatric outcomes.
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Affiliation(s)
- Frederique A Jacquerioz
- Center for Evidence-Based Global Health, Tulane School of Public Health and Tropical Medicine, 1440 Canal Street, TDW, Ste 1820, New Orleans, Louisiana, USA, 70115
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Premji Z, Umeh RE, Owusu-Agyei S, Esamai F, Ezedinachi EU, Oguche S, Borrmann S, Sowunmi A, Duparc S, Kirby PL, Pamba A, Kellam L, Guiguemdé R, Greenwood B, Ward SA, Winstanley PA. Chlorproguanil-dapsone-artesunate versus artemether-lumefantrine: a randomized, double-blind phase III trial in African children and adolescents with uncomplicated Plasmodium falciparum malaria. PLoS One 2009; 4:e6682. [PMID: 19690618 PMCID: PMC2724683 DOI: 10.1371/journal.pone.0006682] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [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: 02/05/2009] [Accepted: 03/17/2009] [Indexed: 11/29/2022] Open
Abstract
Background Chlorproguanil−dapsone−artesunate (CDA) was developed as an affordable, simple, fixed-dose artemisinin-based combination therapy for use in Africa. This trial was a randomized parallel-group, double-blind, double-dummy study to compare CDA and artemether−lumefantrine (AL) efficacy in uncomplicated Plasmodium falciparum malaria and further define the CDA safety profile, particularly its hematological safety in glucose-6-phosphate dehydrogenase (G6PD) -deficient patients. Methods and Findings The trial was conducted at medical centers at 11 sites in five African countries between June 2006 and August 2007. 1372 patients (≥1 to <15 years old, median age 3 years) with acute uncomplicated P. falciparum malaria were randomized (2∶1) to receive CDA 2/2.5/4 mg/kg once daily for three days (N = 914) or six-doses of AL over three days (N = 458). Non-inferiority of CDA versus AL for efficacy was evaluated in the Day 28 per-protocol (PP) population using parasitological cure (polymerase chain reaction [PCR]-corrected). Cure rates were 94.1% (703/747) for CDA and 97.4% (369/379) for AL (treatment difference –3.3%, 95%CI –5.6, −0.9). CDA was non-inferior to AL, but there was simultaneous superiority of AL (upper 95%CI limit <0). Adequate clinical and parasitological response at Day 28 (uncorrected for reinfection) was 79% (604/765) with CDA and 83% (315/381) with AL. In patients with a G6PD-deficient genotype (94/603 [16%] hemizygous males, 22/598 [4%] homozygous females), CDA had the propensity to cause severe and clinically concerning hemoglobin decreases: the mean hemoglobin nadir was 75 g/L (95%CI 71, 79) at Day 7 versus 97 g/L (95%CI 91, 102) for AL. There were three deaths, unrelated to study medication (two with CDA, one with AL). Conclusions Although parasitologically effective at Day 28, the hemolytic potential of CDA in G6PD-deficient patients makes it unsuitable for use in a public health setting in Africa. Trial Registration ClinicalTrials.gov NCT00344006
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Affiliation(s)
- Zul Premji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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Atovaquone + proguanil: new indication. For children weighing as little as 5 kg; an inconvenient form. A flavoured syrup would be better suited to infants and young children. Prescrire Int 2009; 18:113. [PMID: 19637424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Mutabingwa TK, Muze K, Ord R, Briceño M, Greenwood BM, Drakeley C, Whitty CJM. Randomized trial of artesunate+amodiaquine, sulfadoxine-pyrimethamine+amodiaquine, chlorproguanal-dapsone and SP for malaria in pregnancy in Tanzania. PLoS One 2009; 4:e5138. [PMID: 19352498 PMCID: PMC2662423 DOI: 10.1371/journal.pone.0005138] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [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: 06/22/2008] [Accepted: 03/13/2009] [Indexed: 11/25/2022] Open
Abstract
Background Malaria in pregnancy is serious, and drug resistance in Africa is spreading. Drugs have greater risks in pregnancy and determining the safety and efficacy of drugs in pregnancy is therefore a priority. This study set out to determine the efficacy and safety of several antimalarial drugs and combinations in pregnant women with uncomplicated malaria. Methods Pregnant women with non-severe, slide proven, falciparum malaria were randomised to one of 4 regimes: sulfadoxine-pyrimethamine [SP]; chlorproguanil-dapsone [CD]; SP+amodiaquine [SP+AQ] or amodiaquine+artesunate [AQ+AS]. Randomisation was on a 1∶2∶2∶2 ratio. Women were admitted for treatment, and followed at days 7, 14, 21, 28 after the start of treatment, at delivery and 6 weeks after delivery to determine adverse events, clinical and parasitological outcomes. Primary outcome was parasitological failure by day 28. Results 1433 pregnant women were screened, of whom 272 met entry criteria and were randomised; 28 to SP, 81 to CD, 80 to SP+AQ and 83 to AQ+AS. Follow-up to day 28 post treatment was 251/272 (92%), and to 6 weeks following delivery 91%. By day 28 parasitological failure rates were 4/26 (15%, 95%CI 4–35) in the SP, 18/77 (23%, 95%CI 14–34) in the CD, 1/73 (1% 95%CI 7–0.001) in the SP+AQ and 7/75 (9% 95%CI 4–18) in the AQ+AS arms respectively. After correction by molecular markers for reinfection the parasitological failure rates at day 28 were 18% for CD, 1% for SP+AQ and 4.5% for AQ+AS. There were two maternal deaths during the trial. There was no apparent excess of stillbirths or adverse birth outcomes in any arm. Parasitological responses were strikingly better in pregnant women than in children treated with the same drugs at this site. Conclusions Failure rates with monotherapy were unacceptably high. The two combinations tested were efficacious and appeared safe. It should not be assumed that efficacy in pregnancy is the same as in children. Trial Registration ClinicalTrials.gov NCT00146731
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Affiliation(s)
- Theonest K Mutabingwa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.
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Haubitz S, Saur M, Weber R. [Fever in returning travellers]. Praxis (Bern 1994) 2009; 98:303-310. [PMID: 19291636 DOI: 10.1024/1661-8157.98.6.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Sebastian Haubitz
- Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich, Germany.
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Ogunfowokan O, Dankyau M, Madaki AJK, Thacher TD. Short report: comparison of chlorproguanil-dapsone with a combination of sulfadoxine-pyrimethamine and chloroquine in children with malaria in northcentral Nigeria. Am J Trop Med Hyg 2009; 80:199-201. [PMID: 19190213] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Effective and affordable treatment of malaria is critical in the face of resistance of Plasmodium falciparum to chloroquine (CQ) and sulfadoxine-pyrimethamine (SP). We conducted a randomized controlled trial comparing the efficacy of chlorproguanil-dapsone (CD) with a combination SP plus CQ in children in Nigeria less than five years of age with malaria. Of 264 children enrolled, 122 (89.7%) and 118 (92.2%) completed the study in the SP + CQ and CD groups, respectively. By day 3, 96 (78.7%) and 94 (79.7%) had cleared their parasitemia (P = 0.79), and 107 (87.7%) and 109 (92.4%) were symptom free (P = 0.32) in the SP + CQ and CD groups, respectively. Adequate clinical and parasitologic response at day 14 occurred in 111 (94.1%; 95% confidence interval [CI] = 91.6-95.7%) in the CD group and 113 (92.6%; 95% CI = 89.9-94.3%) in the SP + CQ group (P = 0.85). SP + CQ and CD had similar antimalarial efficacy and still provide affordable treatment of uncomplicated malaria in northcentral Nigeria.
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Affiliation(s)
- Oluwagbenga Ogunfowokan
- Department of Family Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria.
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Owusu-Agyei S, Asante KP, Owusu R, Adjuik M, Amenga-Etego S, Dosoo DK, Gyapong J, Greenwood B, Chandramohan D. An open label, randomised trial of artesunate+amodiaquine, artesunate+chlorproguanil-dapsone and artemether-lumefantrine for the treatment of uncomplicated malaria. PLoS One 2008; 3:e2530. [PMID: 18575626 PMCID: PMC2430614 DOI: 10.1371/journal.pone.0002530] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [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: 09/03/2007] [Accepted: 05/09/2008] [Indexed: 11/19/2022] Open
Abstract
Background Artesunate+amodiaquine (AS+AQ) and artemether-lumefantrine (AL) are now the most frequently recommended first line treatments for uncomplicated malaria in Africa. Artesunate+chlorproguanil-dapsone (AS+CD) was a potential alternative for treatment of uncomplicated malaria. A comparison of the efficacy and safety of these three drug combinations was necessary to make evidence based drug treatment policies. Methods Five hundred and thirty-four, glucose-6-phosphate dehydrogenase (G6PD) normal children were randomised in blocks of 15 to the AS+AQ, AL or AS+CD groups. Administration of study drugs was supervised by project staff and the children were followed up at r home on days 1,2,3,7,14 and 28 post treatment. Parasitological and clinical failures and adverse events were compared between the study groups. Main Findings In a per-protocol analysis, the parasitological and clinical failure rate at day 28 post treatment (PCF28) was lower in the AS+AQ group compared to the AL or AS+CD groups (corrected for re-infections: 6.6% vs 13.8% and 13.8% respectively, p = 0.08; uncorrected: 14.6% vs 27.6% and 28.1% respectively, p = 0.005). In the intention to treat analysis, the rate of early treatment failure was high in all three groups (AS+AQ 13.3%; AL 15.2%; and AS+CD 9.3%, p = 0.2) primarily due to vomiting. However, the PCF28 corrected for re-infection was lower, though not significantly, in the AS+AQ group compared to the AL or the AS+CD groups (AS+AQ 18.3%; AL 24.2%; AS+CD 20.8%, p = 0.4) The incidence of adverse events was comparable between the groups. Conclusions AS+AQ is an appropriate first line treatment for uncomplicated malaria in Ghana and possibly in the neighbouring countries in West Africa. The effectiveness of AL in routine programme conditions needs to be studied further in West Africa. Trial Registration ClinicalTrials.gov NCT00119145
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Affiliation(s)
- Seth Owusu-Agyei
- Kintmapo Health Research Centre, Ministry of Health, Kintampo, Ghana
- Infectious and Tropical Diseases Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kwaku Poku Asante
- Kintmapo Health Research Centre, Ministry of Health, Kintampo, Ghana
| | - Ruth Owusu
- Kintmapo Health Research Centre, Ministry of Health, Kintampo, Ghana
| | - Martin Adjuik
- Navrongo Health Research Centre, Ministry of Health, Navrongo, Ghana
| | | | - David Kwame Dosoo
- Kintmapo Health Research Centre, Ministry of Health, Kintampo, Ghana
| | - John Gyapong
- Heatlh Research Unit, Ministry of Health, Accra, Ghana
| | - Brian Greenwood
- Infectious and Tropical Diseases Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Daniel Chandramohan
- Infectious and Tropical Diseases Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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Kaye DK, Nshemerirwe R, Mutyaba TS, Ndeezi G. A randomized clinical trial comparing safety, clinical and parasitological response to artemether-lumefantrine and chlorproguanil-dapsone in treatment of uncomplicated malaria in pregnancy in Mulago hospital, Uganda. J Infect Dev Ctries 2008; 2:135-139. [PMID: 19738339] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Malaria infection during pregnancy is a major public health problem. Due to increasing resistance to Chloroquine and Sulphadoxine/Pyrimethamine, the Ugandan national policy on malaria treatment was changed in 2005 to Artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria. The policy recommends assessment of safety and efficacy of alternative drugs for treatment of uncomplicated malaria. We compared the efficacy and safety of Artemether-Lumefantrine (Coartem) and Chlorproguanil-Dapsone (Lapdap) in the management of uncomplicated malaria in pregnancy. METHODOLOGY We enrolled 110 pregnant women in the second and third trimester of pregnancy who presented to Mulago hospital, Uganda, with uncomplicated malaria. The study design was an open-label randomized clinical trial. Participants were randomized to receive either Artemether-Lumefantrine (Coartem 20 mg/120 mg) orally or Chlorproguanil-Dapsone (Lapdap) orally for 3 consecutive days. Primary endpoints were clinical and parasitological response assessed on days 0, 1, 2, 4, 7, 14 and 28. Adverse effects, clinical response (treatment failure) and parasitological response were compared. Analysis was by intention to treat. RESULTS Of the 100 women who completed the study, there was no statistically significant difference in clinical and parasitological response by Day 4. The mean fever clearance time 3.0 days with Lapdap versus 2.5 days with Coartem was comparable. Likewise, mean parasite clearance time of 2.4 and 2.2 days for Lapdap and Coartem respectively was comparable. The adverse effects were comparable between the two groups. CONCLUSION Artemether-Lumefantrine and Chlorproguanil-Dapsone have high and comparable cure rates and similar safety profiles when used for treatment of uncomplicated malaria in pregnancy.
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Affiliation(s)
- Daniel Kabonge Kaye
- Department of Obstetrics and Gynecology, Makerere University Medical School, PO Box 7072, Kampala, Uganda.
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Artemether + lumefantrine: new drug. An alternative to atovaquone + proguanil. Prescrire Int 2008; 17:54-6. [PMID: 18516806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
(1) Treatment of uncomplicated malaria acquired in areas of chloroquine resistance is based on oral drugs chosen according to local resistance patterns. The atovaquone + proguanil combination is often the first choice for travelers because of its tolerability and convenience. (2) For the treatment of uncomplicated malaria, artemisinin derivatives, extracted from a Chinese plant, have a short-lived action and should not therefore be used as monotherapy. (3) Only one combination of this type, artemether plus lumefantrine (an antimalarial related to halofantrine), is marketed in France for the treatment of uncomplicated malaria. (4) In African trials, the efficacy of the artemether + lumefantrine combination, taken in 6 doses over 3 days, was fairly consistent and similar (or even superior) to that of the amodiaquine + sulfadoxine + pyrimethamine combination in three trials. It was more effective than the quinine + doxycycline combination in a region of Brazil where strains with diminished sensitivity to quinine circulate. (5) Artemether has the adverse effects of all artemisinin derivatives, especially gastrointestinal and neurological disorders. Lumefantrine, a drug related to halofantrine, prolongs the QT interval (albeit less than halofantrine), and this sometimes warrants ECG monitoring and blood potassium assays, especially in patients who have hepatic or renal failure or who are taking other drugs that affect the QT interval. (6) The absorption of lumefantrine is dependent on the presence of food in the stomach, which can be difficult as loss of appetite and nausea are frequent during malaria attacks. Intake of about 1.5 g of fat seems sufficient for satisfactory absorption. The artemether + lumefantrine combination is effective in case of resistance to other antimalarials. It is an alternative to the atovaquone + proguanil combination for travelers.
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Wootton DG, Opara H, Biagini GA, Kanjala MK, Duparc S, Kirby PL, Woessner M, Neate C, Nyirenda M, Blencowe H, Dube-Mbeye Q, Kanyok T, Ward S, Molyneux M, Dunyo S, Winstanley PA. Open-label comparative clinical study of chlorproguanil-dapsone fixed dose combination (Lapdap) alone or with three different doses of artesunate for uncomplicated Plasmodium falciparum malaria. PLoS One 2008; 3:e1779. [PMID: 18320064 PMCID: PMC2258152 DOI: 10.1371/journal.pone.0001779] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [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: 08/28/2007] [Accepted: 01/17/2008] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED The objective of this study was to determine the appropriate dose of artesunate for use in a fixed dose combination therapy with chlorproguanil-dapsone (CPG-DDS) for the treatment of uncomplicated falciparum malaria. METHODS Open-label clinical trial comparing CPG-DDS alone or with artesunate 4, 2, or 1 mg/kg at medical centers in Blantyre, Malawi and Farafenni, The Gambia. The trial was conducted between June 2002 and February 2005, including 116 adults (median age 27 years) and 107 children (median age 38 months) with acute uncomplicated Plasmodium falciparum malaria. Subjects were randomized into 4 groups to receive CPG-DDS alone or plus 4, 2 or 1 mg/kg of artesunate once daily for 3 days. Assessments took place on Days 0-3 in hospital and follow-up on Days 7 and 14 as out-patients. Efficacy was evaluated in the Day 3 per-protocol (PP) population using mean time to reduce baseline parasitemia by 90% (PC90). A number of secondary outcomes were also included. Appropriate artesunate dose was determined using a pre-defined decision matrix based on primary and secondary outcomes. Treatment emergent adverse events were recorded from clinical assessments and blood parameters. Safety was evaluated in the intent to treat (ITT) population. RESULTS In the Day 3 PP population for the adult group (N = 85), mean time to PC90 was 19.1 h in the CPG-DDS group, significantly longer than for the +artesunate 1 mg/kg (12.5 h; treatment difference -6.6 h [95%CI -11.8, -1.5]), 2 mg/kg (10.7 h; -8.4 h [95%CI -13.6, -3.2]) and 4 mg/kg (10.3 h; -8.7 h [95%CI -14.1, -3.2]) groups. For children in the Day 3 PP population (N = 92), mean time to PC90 was 21.1 h in the CPG-DDS group, similar to the +artesunate 1 mg/kg group (17.7 h; -3.3 h [95%CI -8.6, 2.0]), though the +artesunate 2 mg/kg and 4 mg/kg groups had significantly shorter mean times to PC90 versus CPG-DDS; 14.4 h (treatment difference -6.4 h [95%CI -11.7, -1.0]) and 12.8 h (-7.4 h [95%CI -12.9, -1.8]), respectively. An analysis of mean time to PC90 for the Day 14 PP and ITT populations was consistent with the primary analysis. Treatment emergent, drug-related adverse events were experienced in 35.3% (41/116) of adults and 70.1% (75/107) of children; mostly hematological and gastroenterological. The nature and incidence of adverse events was similar between the groups. No dose-related changes in laboratory parameters were observed. Nine serious adverse events due to any cause occurred in five subjects including two cases of hemolysis believed to be associated with drug treatment (one adult, one child). One adult died of anaphylactic shock, not associated with investigational therapy. CONCLUSIONS CPG-DDS plus artesunate demonstrated advantages over CPG-DDS alone for the primary efficacy endpoint (mean time to PC90) except in children for the 1 mg/kg artesunate dose. Based on a pre-defined decision matrix, the primary endpoint in the child group supported an artesunate dose of 4 mg/kg. Secondary endpoints also supported a 4 mg/kg artesunate dose to take forward into the remainder of the development program. TRIAL REGISTRATION ClinicalTrials.gov NCT00519467.
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Affiliation(s)
- Daniel G. Wootton
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Major Overseas Programme, College of Medicine, Blantyre, Malawi
| | | | | | - Maxwell K. Kanjala
- Malawi-Liverpool-Wellcome Trust Major Overseas Programme, College of Medicine, Blantyre, Malawi
| | | | | | - Mary Woessner
- GlaxoSmithKline, Greenford, Middlesex, United Kingdom
| | - Colin Neate
- GlaxoSmithKline, Greenford, Middlesex, United Kingdom
| | - Maggie Nyirenda
- Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Hannah Blencowe
- Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Queen Dube-Mbeye
- Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Thomas Kanyok
- Global Health-Infectious Diseases, Bill and Melinda Gates Foundation, Seattle, Washington, United States of America (formerly at the WHO-UNDP-World Bank Special Programme for Research and Training in Tropical Medicine (WHO-TDR), Geneva, Switzerland)
| | - Stephen Ward
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Malcolm Molyneux
- Malawi-Liverpool-Wellcome Trust Major Overseas Programme, College of Medicine, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sam Dunyo
- MRC Laboratories, Banjul, Fajara, The Gambia
| | - Peter A. Winstanley
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, United Kingdom
- * To whom correspondence should be addressed. E-mail:
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Senn N, D'Acremont V, Landry P, Genton B. Malaria chemoprophylaxis: what do the travelers choose, and how does pretravel consultation influence their final decision. Am J Trop Med Hyg 2007; 77:1010-1014. [PMID: 18165513] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Three different drugs (mefloquine, atovaquone/proguanil, doxycycline) are recommended for malaria chemoprophylaxis, each with approximately the same efficacy but various adverse event profiles, regimens, and prices. We investigated which medication the travelers would have chosen on the basis of written evidence-based information and the impact that pretravel consultation had on their decision. A prospective study was performed in a travel clinic and private practice, and 1073 travelers were included; 45% chose mefloquine (Lariam or Mephaquine), 21% atovaquone/proguanil (Malarone), 18% doxycycline (Supracycline), 5% "no prophylaxis," and 11% "do not know." Lariam was principally chosen because of prior experience (38%), Mephaquine because of low price (34%), and doxycycline and Malarone because of the profile of adverse events (55% and 43%, respectively). Based on objective written information, travelers most frequently chose mefloquine for chemoprophylaxis. This suggests that evidence-based information weighs more heavily than negative publicity. Taking into account the perspective of the user should improve appropriateness of the pretravel advice.
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Affiliation(s)
- Nicolas Senn
- Travel Clinic, Department of Ambulatory Care and Community Medicine, Switzerland.
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Massey P, Durrheim DN, Speare R. Inadequate chemoprophylaxis and the risk of malaria. Aust Fam Physician 2007; 36:1058-1060. [PMID: 18075636] [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] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Malaria is an important disease for Australian travellers, particularly to Papua New Guinea. Travellers often seek health advice from their general practitioner before travel or if they develop illness after travel. METHOD A retrospective cohort investigation into malaria risk in a group of adult Australians that trekked the Kokoda trail in Papua New Guinea. RESULTS Six of 38 group members were diagnosed with malaria on return from Papua New Guinea. None of the 12 individuals who took chemoprophylaxis for the recommended period post-travel developed malaria compared to 4/24 travellers who terminated prophylaxis prematurely or 2/2 who took no chemoprophylaxis. DISCUSSION Chemoprophylaxis is effective if taken for the full recommended period following travel to a malaria endemic area; 4 weeks for doxycycline and mefloquine, and 7 days for atovaquone+proguanil. Malaria is a likely cause of illness in recently returned travellers from Papua New Guinea who develop a febrile illness.
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Affiliation(s)
- Peter Massey
- CNC, Population Health, Hunter New England Health, Tamworth, New South Wales.
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Abstract
BACKGROUND Plasmodium falciparum (Pf) malaria is a leading cause of childhood mortality and morbidity. In developed countries, it is widely recommended that even patients with uncomplicated Pf malaria are hospitalised for at least 24 h, whereas ambulatory treatment is usual for uncomplicated infections in developing countries. This observational study assessed the safety of selective admission of paediatric refugees with Pf malaria in Australia. METHODS Data were collected on African humanitarian refugee children (<16 years of age) presenting with malaria between February 2005 and April 2006. Children were treated as outpatients if they fulfilled specific criteria devised to maximise the safety of outpatient management of this potentially life-threatening condition. RESULTS Ninety paediatric refugees were infected with P falciparum, of whom 56 were treated as outpatients. Of the 34 children admitted to hospital, four had parasite loads > or =4%. Most children were treated with oral atovaquone-proguanil. Eighty eight patients attended follow-up; all were compliant and none reported side-effects. One infant failed treatment and was subsequently readmitted; he did not meet criteria for severe malaria on either occasion and had been initially treated as an inpatient. CONCLUSIONS Using this protocol, outpatient management of refugee children with Pf malaria appears safe, with minimal complication and treatment failure rates. This approach has rationalised management of paediatric malaria in this carefully selected population and substantially reduced utilisation of hospital resources.
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Affiliation(s)
- Sarah Cherian
- School of Paediatrics and Child Health, University of Western Australia and Paediatric Infectious Diseases and Refugee Health, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Abstract
There are reports of patients with sickle cell disease who developed hematological malignancies but the relationship between these malignancies and sickle cell disease (SCD) is not yet defined. The co-existence of a hematological malignancy with SCD poses certain challenges for the management of each condition. We describe a 7-year-old boy with sickle cell anemia who developed Hodgkin's lymphoma and the challenges of management. He presented with a 4-year history of bilateral neck swelling and a 2-month history of weight loss and high-grade fever. Histology of a lymph node biopsy was consistent with mixed cellularity Hodgkin's lymphoma. He was treated with five cycles of Cyclophosphamide, Vincristine, Procarbazine and Prednisolone (COPP) and had complete clinical response. Chemotherapy was associated with an increase in frequency of painful crises and complicated by septicaemia. Blood transfusion needs were minimal; apart from the transfusion preceding the first cycle of chemotherapy, there was no need for further transfusion. Myelosuppression was not a problem in the patient; he responded well to antibiotics during the two episodes of septicemia without the use of hemopoetic growth factor. Patients with sickle cell anaemia who develop Hodgkin's lymphoma can be successfully treated with chemotherapy along with supportive management for crises and infections.
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Affiliation(s)
- Biobele J Brown
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria.
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Abstract
Combination drug therapy for malaria is recommended both to prevent and to overcome drug resistance. Drug combinations developed for use in Asia are being deployed in Africa, where higher rates of malaria affect the therapeutic and public health objectives of malaria chemotherapy as well as drug safety. Rational consideration of drug mechanisms, pharmacokinetics (PK), pharmacodynamics (PD), and malaria epidemiology should result in more effective combination regimens that retain therapeutic and prophylactic efficacy in the face of resistance.
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Affiliation(s)
- M M Nyunt
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Nakato H, Vivancos R, Hunter PR. A systematic review and meta-analysis of the effectiveness and safety of atovaquone proguanil (Malarone) for chemoprophylaxis against malaria. J Antimicrob Chemother 2007; 60:929-36. [PMID: 17848375 DOI: 10.1093/jac/dkm337] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES A systematic review and meta-analysis of the effectiveness of atovaquone-proguanil (Malarone) as a chemoprophylactic agent against malaria. METHODS The data sources searched for this study included Cochrane systematic reviews (on infectious diseases), MEDLINE and EMBASE, Web of Knowledge and Annals of Tropical Medicine. All unconfounded randomized controlled trials assessing the chemoprophylaxis against malaria with atovaquone-proguanil were included in the review. Data on study design, study sample, inclusion and exclusion criteria, allocation, blinding, primary and secondary study end points were all extracted by one reviewer and independently rechecked by the second reviewer. RESULTS In general, all 10 studies identified had excellent quality with total scores of >or=4 using the Jadad criteria. Ten controlled trials comprising 4,539 participants were included for this review. A meta-analysis of six of the ten studies found chemoprophylaxis with atovaquone-proguanil, with a prophylaxis efficacy of 95.8% (95% CI = 91.5-97.9), to be superior to placebo. It was also considered safe and better tolerated with fewer treatment-related adverse events that could lead to premature discontinuation of prophylaxis than in controls. Comparison with alternative chemoprophylaxis also showed atovaquone-proguanil to be better tolerated with fewer treatment-related self-reported adverse events (RR = 0.8234; 95% CI = 0.673164-1.01) or severe adverse events (RR = 0.6140; 95% CI = 0.420055-0.8975). Atovaquone-proguanil is well tolerated with no difference in non-compliance with placebo (RR = 0.8804; 95% CI = 0.6964-1.113; I(2) = 31.4%). CONCLUSIONS Evidence from this review shows that atovaquone-proguanil is highly efficacious as a prophylactic agent against malaria infection and is very well tolerated compared with other antimalarial agents.
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Affiliation(s)
- Halima Nakato
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK
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