Abstract
BackgroundThe burden of Plasmodium falciparum malaria has worsened because of the emergence of chloroquine resistance. Antimalarial drug use and drug pressure are critical factors contributing to the selection and spread of resistance. The present study explores the geographical, socio-economic and behavioural factors associated with the use of antimalarial drugs in Africa.MethodsThe presence of chloroquine (CQ), pyrimethamine (PYR) and other antimalarial drugs has been evaluated by immuno-capture and high-performance liquid chromatography in the urine samples of 3,052 children (2–9 y), randomly drawn in 2003 from the general populations at 30 sites in Senegal (10), Burkina-Faso (10) and Cameroon (10). Questionnaires have been administered to the parents of sampled children and to a random sample of households in each site. The presence of CQ in urine was analysed as dependent variable according to individual and site characteristics using a random – effect logistic regression model to take into account the interdependency of observations made within the same site.ResultsAccording to the sites, the prevalence rates of CQ and PYR ranged from 9% to 91% and from 0% to 21%, respectively. In multivariate analysis, the presence of CQ in urine was significantly associated with a history of fever during the three days preceding urine sampling (OR = 1.22, p = 0.043), socio-economic level of the population of the sites (OR = 2.74, p = 0.029), age (2–5 y = reference level; 6–9 y OR = 0.76, p = 0.002), prevalence of anti-circumsporozoite protein (CSP) antibodies (low prevalence: reference level; intermediate level OR = 2.47, p = 0.023), proportion of inhabitants who lived in another site one year before (OR = 2.53, p = 0.003), and duration to reach the nearest tarmacked road (duration less than one hour = reference level, duration equal to or more than one hour OR = 0.49, p = 0.019).ConclusionAntimalarial drug pressure varied considerably from one site to another. It was significantly higher in areas with intermediate malaria transmission level and in the most accessible sites. Thus, P. falciparum strains arriving in cross-road sites or in areas with intermediate malaria transmission are exposed to higher drug pressure, which could favour the selection and the spread of drug resistance.
Highlights
The burden of Plasmodium falciparum malaria has worsened because of the emergence of chloroquine resistance
Uncontrolled antimalarial drug use is a critical factor that contributes to the drug pressure
The prevalence of P. falciparum trophozoites was significantly (p < 0.05) different between sites. It varied from 16.2% to 96.1% (Table 2), with a median of 72%. It was significantly higher in the south than in the north of Senegal (72% versus 25%, p < 10-3), Burkina Faso (79% versus 64%, p < 103), and Cameroon (78% versus 61%, p < 10-3), and higher in rural than in urban areas of Burkina Faso (84% versus 64%, p < 10-3)
Summary
The burden of Plasmodium falciparum malaria has worsened because of the emergence of chloroquine resistance. Antimalarial drug use and drug pressure are critical factors contributing to the selection and spread of resistance. The present study explores the geographical, socio-economic and behavioural factors associated with the use of antimalarial drugs in Africa. Several studies have described a two-fold increase in deaths due to malaria during the 1980s and 1990s because of the emergence of the chloroquine resistance [2,3,4]. Intensity of malaria transmission and population movement favour the spread of antimalarial drug resistance [8,9,10]. In order to evaluate the association between the use of antimalarial drug and geographical, socio-economic and behavioral factors, a multi center cross-sectional study was conducted in 2003 in 30 sites from three countries (Senegal, Burkina Faso and Cameroon), when CQ was still the first-line treatment of uncomplicated malaria. The sites are not formally representatives of the whole continent, they represent a wide panel of ecosystems and malaria endemicity conditions
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