Artemisinin-based Combination Therapy Research Articles

Assessment of Plasmodium falciparum drug resistance associated molecular markers in Mandla, Madhya Pradesh, India

BackgroundResistance against artemisinin-based combination therapy is one of the challenges to malaria control and elimination globally. Mutations in different genes (Pfdhfr, Pfdhps, Pfk-13 and Pfmdr1) confer resistance to artesunate and sulfadoxine–pyrimethamine (AS + SP) were analysed from Mandla district, Madhya Pradesh, to assess the effectiveness of the current treatment regimen against uncomplicated Plasmodium falciparum.MethodsDried blood spots were collected during the active fever survey and mass screening and treatment activities as part of the Malaria Elimination Demonstration Project (MEDP) from 2019 to 2020. Isolated DNA samples were used to amplify the Pfdhfr, Pfdhps, Pfk13 and Pfmdr1 genes using nested PCR and sequenced for mutation analysis using the Sanger sequencing method.ResultsA total of 393 samples were subjected to PCR amplification, sequencing and sequence analysis; 199, 215, 235, and 141 samples were successfully sequenced for Pfdhfr, Pfdhps, Pfk13, Pfmdr1, respectively. Analysis revealed that the 53.3% double mutation (C59R, S108N) in Pfdhfr, 89.3% single mutation (G437A) in Pfdhps, 13.5% single mutants (N86Y), and 51.1% synonymous mutations in Pfmdr1 in the study area. Five different non-synonymous and two synonymous point mutations found in Pfk13, which were not associated to artemisinin resistance.ConclusionThe study has found that mutations linked to SP resistance are increasing in frequency, which may reduce the effectiveness of this drug as a future partner in artemisinin-based combinations. No evidence of mutations linked to artemisinin resistance in Pfk13 was found, suggesting that parasites are sensitive to artemisinin derivatives in the study area. These findings are a baseline for routine molecular surveillance to proactively identify the emergence and spread of artemisinin-resistant parasites.

Identification of novel compounds and repurposing of FDA drugs for 1-deoxy-D-xylulose 5-phosphate reductoisomerase enzyme of Plasmodium falciparum to combat malaria resistance

The rise of Plasmodium falciparum resistance to Artemisinin-based combination therapies (ACTs) is a significant concern in the fight against malaria. This situation calls for the search for novel anti-malarial candidates. 1-deoxy-D-xylulose 5-phosphate reductoisomerase (IspC) is a potential target involved in various cellular processes in P. falciparum (Pf). We screened ∼0.69 billion novel compounds from the ZINC20 library and repurposed ∼1400 FDA drugs using computational drug discovery methods against PfIspC. Following our computational pipeline, we found five novel ZINC20 compounds (Z-2, Z-3, Z-10, Z-13, and Z-14) and three FDA drugs (Aliskiren, Ceftolozane, and Ombitasvir) that showed striking docking energy (ranging from −8.405 to −10.834 kcal/mol), and strong interactions with key binding site residues (Ser269, Ser270, Ser306, Asn311, Lys312, and Met360) of PfIspC. The novel anti-malarial compounds also exhibited favorable pharmacokinetics and physicochemical properties. Furthermore, through molecular dynamics simulation, we observed the stable dynamics of PfIspC–inhibitor complexes and the influence of inhibitor binding on the protein's conformational arrangements. Notably, the binding free energy estimation confirmed high binding affinity (varied from −11.68 to −33.16 kcal/mol) of these compounds for PfIspC. Our findings could contribute to the ongoing efforts in combating malaria and invite experimental-lab researchers for validation.

Alkaloids as Antimalarial Compounds: A Review of Recent Studies

Abstract: Malaria is a parasitic infection caused by Plasmodium parasites that are transmitted to humans through the bite of infected Anopheles mosquitoes. Malaria continues to contribute unacceptably high rates of sickness and death. Natural product compounds have long been recognized as one of valuable natural remedy resources with promising structural motif pools for the development of first-line drugs. Resistance to conventional treatments such as chloroquine, mefloquine, and artemisinin- based combination therapy (ACT) by the causal agent, the Plasmodium parasite, is a major concern in malaria treatment and prevention globally. Given the parasites' resistance to several current treatment regimens, innovative antimalarial chemotherapeutic medicines derived from tetramic acid alkaloids are desperately needed. In this review, new and old antimalarial alkaloids identified and reported recently from 2017 to 2021 are presented. Several compounds with promising antimalarial activity are identified from several subclasses of alkaloids. It is hoped that this review report will inspire future research into the compounds' toxicity and in vivo efficacy, to exploit this intriguing compound as antimalarial drugs.

Characterisation of populations at risk of sub-optimal dosing of artemisinin-based combination therapy in Africa.

Selection of resistant malaria strains occurs when parasites are exposed to inadequate antimalarial drug concentrations. The proportion of uncomplicated falciparum malaria patients at risk of being sub-optimally dosed with the current World Health Organization (WHO) recommended artemisinin-based combination therapies (ACTs) is unknown. This study aims to estimate this proportion and the excess number of treatment failures (recrudescences) associated with sub-optimal dosing in Sub-Saharan Africa. Sub-populations at risk of sub-optimal dosing include wasted children <5 years of age, patients with hyperparasitaemia, pregnant women, people living with HIV, and overweight adults. Country-level data on population structure were extracted from openly accessible data sources. Pooled adjusted Hazard Ratios for PCR-confirmed recrudescence were estimated for each risk group from published meta-analyses using fixed-effect meta-analysis. In 2020, of the estimated 153.1 million uncomplicated P. falciparum malaria patients in Africa, the largest risk groups were the hyperparasitaemic patients (13.2 million, 8.6% of uncomplicated malaria cases) and overweight adults (10.3 million, 6.7% of uncomplicated cases). The estimated excess total number of treatment failures ranged from 0.338 million for a 98% baseline ACT efficacy to 1.352 million for a 92% baseline ACT efficacy. Our study shows that an estimated nearly 1 in 4 people with uncomplicated confirmed P. falciparum malaria in Africa are at risk of receiving a sub-optimal antimalarial drug dosing. This increases the risk of antimalarial drug resistance and poses a serious threat to malaria control and elimination efforts. Changes in antimalarial dosing or treatment duration of current antimalarials may be needed and new antimalarials development should ensure sufficient drug concentration levels in these sub-populations that carry a high malaria burden.

Experiences of healthcare personnel on the efficacy of artemisinin-based combination therapy and malaria diagnosis in hospitals in Uganda

BackgroundThe risk of widespread resistance to artemisinin-based combination therapy (ACT) remains high in Uganda following detection of Plasmodium falciparum parasites with delayed artemisinin clearance genotype and phenotype. Establishment of context specific interventions to mitigate emergence and spread of artemisinin resistance is thus key in the fight against malaria in the country. The aim of this study was to explore the experiences of healthcare personnel on malaria diagnosis and self-reported efficacy of ACT in the management of malaria symptomatic patients in hospitals in low and high malaria transmission settings in Uganda.MethodsThis was a qualitative study in which data was collected from healthcare personnel in hospitals using key informant interviews. The key informant interview guide was developed, pre-tested prior to use and covered the following areas, (i) sociodemographic characteristics, (ii) malaria diagnosis (clinical and parasite based), (iii) quality-assured artemisinin-based combination therapy, (iv) malaria patient follow-up, (v) artemisinin resistance, (vi) anti-malarial self-medication. Data was entered in Atlas.ti ver 9.0 and analysis done following a framework criterion.ResultsA total of 22 respondents were interviewed of which 16 (72.7%) were clinicians. Majority, 81.8% (18/22) of the respondents were male. The following themes were developed from the analysis, malaria diagnosis (procedures and challenges), use of malaria laboratory test results, malaria treatment in hospitals, use of quality assured ACT (QAACT) in malaria treatment, and efficacy of ACT in malaria treatment.ConclusionMost healthcare personnel-initiated malaria treatment after a positive laboratory test. Cases of malaria patients who report remaining symptomatic after prior use of ACT exist especially in high malaria transmission settings in Uganda. There is need for regular monitoring of artemisinin resistance emergence and spread in the country.

SCHISTOACT: a protocol for an open-label, five-arm, non-inferiority, individually randomized controlled trial of the efficacy and safety of praziquantel plus artemisinin-based combinations in the treatment of Schistosoma mansoni infection

BackgroundSchistosomiasis control relies on praziquantel for preventive chemotherapy. Alternative drugs are needed for the treatment and control of schistosomiasis. Praziquantel is effective against adult schistosome worms but ineffective against larval stages of the parasite and cannot prevent re-infection or interrupt the transmission of infection. Continued reliance on praziquantel for wide-scale schistosomiasis control will likely accelerate the emergence of drug resistance. Artemisinin derivatives are effective against the juvenile stages but ineffective against adult worms. The SCHISTOACT study aimed to evaluate the efficacy and safety of praziquantel plus one of four artemisinin-based combinations in treating Schistosoma mansoni infection in Kenya.MethodsThe SCHISTOACT study is an open-label, head-to-head, five-arm, proof-of-concept, non-inferiority, individually randomized controlled trial with a follow-up of 12 weeks. A total of 540 primary school-aged children from the Mwea area, Kirinyaga County in central Kenya, diagnosed with S. mansoni infection (by Kato-Katz method) are randomly allocated (1:1:1:1:1) to a single dose of praziquantel plus a 3-day course of artesunate-sulfalene/pyrimethamine, or artesunate-amodiaquine, or artesunate plus mefloquine, or dihydroartemisinin-piperaquine, or praziquantel control arm. The primary endpoints are efficacy (cure rate, assessed by microscopy) and safety (adverse events) of each study arm 6 weeks after treatment. Secondary endpoints include cumulative cure rate, egg reduction rate, and re-infection 12 weeks after treatment. The non-inferiority margin is set at − 10 for the risk difference in cure rates between praziquantel and the combined treatment.DiscussionThis study assesses a strategy for repurposing artemisinin-based combination therapies (ACTs) for treating schistosomiasis. It adopts a head-to-head comparison of four different ACTs to test a non-inferiority hypothesis and to strengthen local capacity to conduct clinical trials for interventions against neglected tropical diseases.Trial registrationPan-African Clinical Trials Registry PACTR202001919442161. Retrospectively registered on 6 January 2020

Phytochemical screening, antioxidant analyses, and in vitro and in vivo antimalarial activities of herbal medicinal plant - Rotheca serrata (L.) Steane & Mabb.

Ethnopharmacological relevanceMalaria is a major global health concern that is presently challenged by the emergence of Plasmodium falciparum (Pf) resistance to mainstay artemisinin-based combination therapies (ACTs). Hence, the discovery of novel and effective antimalarial drugs is pivotal to treating and controlling malaria. For many years, traditional plant-based herbal medicines have been employed in the treatment of various illnesses. Rotheca serrata (L.) Steane & Mabb. belongs to the Lamiaceae family that has been traditionally used to treat, cure, and prevent numerous diseases including malaria. AimThe present investigation sought to assess the phytoconstituents, antioxidant, cytotoxicity, antimalarial activities of Rotheca serrata extract and its fractions. The in vitro antiplasmodial activity was assessed in chloroquine-sensitive Pf3D7 and artemisinin-resistant PfCam3.IR539T cultures, and the in vivo antimalarial activity was analyzed in Plasmodium berghei (Pb) ANKA strain-infected BALB/c mouse model. Materials and methodsThe fresh leaves of Rotheca serrata were extracted in methanol (RsMeOH crude leaf extract). A portion of the extract was used to prepare successive solvent fractions using ethyl acetate (RsEA) and hexane (RsHex). The in vitro antiplasmodial activity was evaluated using [3H]-hypoxanthine incorporation assays against Pf3D7 and PfCam3.IR539T cultures. In vitro cytotoxicity study on HeLa, HEK-293T, and MCF-7 cell lines was carried out using MTT assay. The human red blood cells (RBCs) were used to perform the hemolysis assays. In vitro antioxidant studies and detailed phytochemical analysis were performed using GC-MS and FTIR. The four-day Rane's test was performed to evaluate the in vivo antimalarial activity against Pb ANKA strain-infected mice. ResultsPhytochemical quantification of Rotheca serrata extract (RsMeOH) and its fractions (RsEA and RsHex) revealed that RsMeOH crude extract and RsEA fraction had higher contents of total phenol and flavonoid than RsHex fraction. The RsEA fraction showed potent in vitro antiplasmodial activity against Pf3D7 and PfCam3.IR539T with IC50 values of 9.24 ± 0.52 μg/mL and 17.41 ± 0.43 μg/mL, respectively. The RsMeOH crude extract exhibited moderate antiplasmodial activity while the RsHex fraction showed the least antiplasmodial activity. The GC-MS and FTIR analysis of RsMeOH and RsEA revealed the presence of triterpenes, phenols, and hydrocarbons as major constituents. The RsMeOH crude extract was non-hemolytic and non-cytotoxic to HeLa, HEK-293T, and MCF-7 cell lines. The in vivo studies showed that a 1200 mg/kg dose of RsMeOH crude extract could significantly suppress parasitemia by ∼63% and prolong the survival of treated mice by ∼10 days. The in vivo antiplasmodial activity of RsMeOH was better than the RsEA fraction. ConclusionThe findings of this study demonstrated that traditionally used herbal medicinal plants like R. serrata provide a platform for the identification and isolation of potent bioactive phytochemicals that in turn can promote the antimalarial drug research. RsMeOH crude extract and RsEA fraction showed antiplasmodial, antimalarial and antioxidant activities. Chemical fingerprinting analysis suggested the presence of bioactive phytocompounds that are known for their antimalarial effects. Further detailed investigations on RsMeOH crude extract and RsEA fraction would be needed for the identification of the entire repertoire of the active antimalarial components with potent pharmaceutical and therapeutic values.

Distribution of Plasmodium falciparum K13 gene polymorphisms across transmission settings in Ghana

Malaria is a significant global health concern, with a majority of cases in Sub-Saharan African nations. Numerous antimalarial drugs have been developed to counter the rampant prevalence of Plasmodium falciparum malaria. Artemisinin-based Combination Therapy (ACT) has served as the primary treatment of uncomplicated malaria in Ghana since 2005. However, a growing concern has emerged due to the escalating reports of ACT resistance, particularly in Southeast Asia, and its encroachment into Africa. Specifically, mutations in the Kelch propeller domain on chromosome 13 (Pfk13) have been linked to ACT resistance. Yet, our understanding of mutation prevalence in Africa remains largely uncharted. In this study, we compared Pfk13 sequences obtained from 172 P. falciparum samples across three ecological and transmission zones in Ghana. We identified 27 non-synonymous mutations among these sequences, of which two of the mutations, C580Y (found in two samples from the central region) and Y493H (found in one sample from the north), had previously been validated for their association with artemisinin resistance, a phenomenon widespread in Southeast Asia. The Pfk13 gene diversity was most pronounced in the northern savannah than the central forest and south coastal regions, where transmission rates are lower. The observed mutations were not significantly associated with geographical regions, suggesting a frequent spread of mutations across the country. The ongoing global surveillance of artemisinin resistance remains pivotal, and our findings provides insights into the potential spread of resistant parasites in West Africa. Furthermore, the identification of novel codon mutations in this study raises their potential association to ACT resistance, warranting further investigation through in vitro assays to ascertain their functional significance.

A Short Review of Antimalarial Compounds with Sulfonamide Moiety.

Malaria is a public health problem that causes thousands of deaths, primarily in children in African regions. Artemisinin-based combination therapies (ACTs) have helped to save thousands of lives; however, due to Plasmodium's resistance to available treatments, there is a need to search for new low-cost drugs that act through different mechanisms of action to contain this disease. This review shows that compounds with sulfonamide moiety, possibly, act as inhibitors of P. falciparum carbonic anhydrases, moreover, when linked to a variety of heterocycles potentiate the activities of these compounds and may be used in the design of new antimalarial drugs.

Evaluation of the artemisinin content of Artemisia annua L. grown in different Agro ecological zones of Cameroon

Artemisinin and its derivatives are potent antimalarials that have become essential components of Artemisinin Based Combination Therapies (ACTs) for malaria treatment. Production of artemisinin is less compared to its world demand and access to ACTs is still limited in worst hit countries. Secondary metabolite production in plants depends on a number of factors including agro ecology. This work sought to evaluate the growth characteristics and artemisinin content of Artemisia annua grown in four agro ecological zones of Cameroon. Experimental fields comprising of A annua were set up in the different agro-ecological zones, for growth and artemisinin assessments. Artemisinin detection and quantification was compared in leaves/flowers and stems of Artemisia annua from these agro-ecological zones, using High-Performance Liquid Chromatography. Soil provenance and other agro ecological factors significantly affected the growth parameters of A. annua as there were significant differences (p&lt;0.05) in plant height, leaf area, number of branches, stem girth and number of leaves across the different study areas. There was significant variation (P&lt;0.05) in the content of artemisinin from the plant in the different agro ecological zones. The mean levels of artemisinin in the samples was 0.34-0.80% in stem samples, and 0.18-0.61% for leaves/flowers. The highest artemisinin yield in leaf/flowers samples (0.61%) was recorded in samples from Bamenda, while that of stem samples (0.80%) was recorded in samples from Ngaoundere. The study confirms the effect of agro ecological factors on artemisinin content of A. annua in Cameroon and reveal that A. annua grown in most regions of the country contain commercially viable levels of artemisinin which can further be exploited for pharmaceutical purposes.

Comparative Study of Pharmaceutical, Herbal Medicine, and Low-Value Alternating Electromagnetic Radiation as Anti-Malaria Treatment

Malaria is a significant global health burden, particularly in regions with limited healthcare resources. Pharmaceutical interventions, specifically artemisinin-based combination therapies (ACTs), have long been the mainstay of malaria treatment due to their proven efficacy in eliminating Plasmodium parasites. Herbal medicine has also gained attention as a potential alternative or adjunctive therapy. Nevertheless, the emergence of drug-resistant strains, notably in Southeast Asia and Africa, poses a considerable challenge to the effectiveness of these pharmaceutical treatments. Using low-value alternating electromagnetic field (EMF) radiation as an anti-malaria treatment is a novel approach that requires further investigation to determine its therapeutic potential. This research studies the comparative analysis of the effect of pharmaceutical intervention, herbal medicine, and low-value alternating EMF as anti-malaria treatments. The research methodology involves a systematic literature review of relevant scientific databases, design, construction, and administration of 20mT &amp; 30mT electromagnetic field, Lumartem and Thitonia Diversifolia (Jume 12) to plasmodium berghei-infected mice for four days consecutively at the same time interval. Results revealed that all treatments were significantly effective. Lumartem is maximally effective from the third day, while Tihonia Diversifolia was maximally effective on the second day. EMF 10mT was maximally effective on the third day, while EMF 20mT did not fully align with the non-infected mice trend, but it is likely to align if treatment continues. The results of this comparative study will contribute to the body of knowledge regarding the effectiveness of pharmaceutical, herbal medicine, and low-value alternating electromagnetic field treatments for malaria.

Prevalence of multi drug resistance malaria among patients aged 0 – 14 years attending murtala muhammad specialist hospital Kano State, Nigeria

The Plasmodium falciparum multidrug resistance gene 1 (pfmdr1) is a molecular marker of parasite susceptibility to anti-malarial drugs. This study aimed to evaluate multidrug resistance resistance gene 1 (MDR1) mutation in 0-14years old malaria patients attending Murtala Muhammad Specialist Hospital, Kano, Nigeria. Samples from 100 children with malaria were examined to confirm the malaria parasite density and further genotyped via BigDye (v3.1) terminator cycle sequencing for the presence of two SNPs in pfmdr1on samples with high and moderate parasite densities. All data were analyzed using Pearson Chi square and Fisher’s exact (FE) tests. Of the 100 patients, 57% had low (+) malaria parasite density, 28% had moderate (++) and 15% had high (+++) malaria parasite densities of the 100 samples, 31 samples were successfully amplified and analyzed for the pfmdr1 gene located at codon 86 with amplicon size of 534bp while only 7 samples were successfully amplified for the pfmdr1 gene located at codon 1246.Pfmdr1-N86Y mutation was detected in 1 (3.2%) sample. In addition, only 1 (3.2%) sample with allelic change at 1246Y was detected in mutant pfmdr1gene. The result also showed that sex had no significant association (P = 0.4237) with pfmdr1SNP mutation. However, significant association (P = 0.0043) between the age groups (1 month to 14 years) represented in the study and pfmdr1mutation. The present study suggests that strains of P. falciparum with reduced sensitivity to the artemisinin component of artemisinin-based combination therapy (ACT) exist in Kano state, northern Nigeria. Methods: sample Collection Finger prick filter paper blood samples were collected from patients below the age of 5 years. However, 2 mL of venous blood was drawn using sterile syringe and needle from children aged 6 and 14 years. Safety procedures were adopted in the collection of blood samples by swabbing the area to be sampled with disinfectant and allowing it to dry before collection.

Exploring the feasibility of introducing triple artemisinin-based combination therapy in the malaria treatment policy in Vietnam

BackgroundThis study investigates the processes regarding changing malaria treatment policies in Vietnam. Moreover, it explores the feasibility of introducing triple artemisinin-based combination therapy (TACT) in Vietnam to support the national malaria control and elimination plan.MethodsData were collected via 12 in-depth interviews with key stakeholders, combined with a review of policy documents.ResultsTACT is considered as a useful backup strategy in case future treatment failures with current artemisinin-based combination therapy (ACT) would occur. Moreover, TACT is also considered as a promising strategy to prevent the re-establishment of malaria. However, regulatory procedures and implementation timelines for TACT were expected to be lengthy. Therefore, strategies to engage national decision-makers, regulators, and suppliers should be initiated soon, stipulating the benefits of TACT deployment. In Vietnam, a procedure to apply for an import permit without registration that has previously been applied to the introduction of artesunate-pyronaridine was proposed to accelerate the introduction of TACT. Global-level support through the World Health Organization recommendations and prequalification were considered critical for supporting the introduction of TACT in Vietnam.ConclusionsAppropriate approach strategies and early stakeholder engagement will be needed to accelerate the introduction of TACT in Vietnam.

Drug selection pressure and fitness cost for artemether-resistant Plasmodium berghei ANKA parasites in vivo

The clinical use of artemisinin-based combination therapies is threatened by increasing failure rates due to the emergence and spread of multiple drug resistance genes in most human Plasmodium strains. The aim of this study was to generate artemether-resistant (AMR) parasites from Plasmodium berghei ANKA (AMS), and determine their fitness cost. Artemether resistance was generated by increasing drug pressure doses gradually for 9 months. Effective doses (ED50 and ED90) were determined using the 4-day suppressive test, and the indices of resistance (I) at 50% and 90% (I50 and I90) were determined using the ratio of either ED50 or ED90 of AMR to AMS, respectively. The stability of the AMR parasites was evaluated by: five drug-free passages (5DFPs), 3 months of cryopreservation (CP), and drug-free serial passages (DFSPs) for 4 months. Analysis of variance was used to compare differences in growth rates between AMR and AMS with 95% confidence intervals. ED50 and ED90 of AMS were 0.61 and 3.43 mg/kg/day respectively. I50 and I90 after 20 cycles of artemether selection pressure were 19.67 and 21.45, respectively; 5DFP values were 39.16 and 15.27, respectively; 3-month CP values were 29.36 and 10.79, respectively; and DFSP values were 31.34 and 12.29, respectively. The mean parasitaemia value of AMR (24.70% ± 3.60) relative to AMS (37.66% ± 3.68) at Day 7 post infection after DFSPs revealed a fitness cost of 34.41%. A moderately stable AMRP. berghei line was generated. Known and unknown mutations may be involved in modulating artemether resistance, and therefore molecular investigations are recommended.

Amodiaquine drug pressure selects nonsynonymous mutations in pantothenate kinase 1, diacylglycerol kinase, and phosphatidylinositol-4 kinase in Plasmodium berghei ANKA

Background Lumefantrine (LM), piperaquine (PQ), and amodiaquine (AQ), the long-acting components of the artemisinin-based combination therapies (ACTs), are a cornerstone of malaria treatment in Africa. Studies have shown that PQ, AQ, and LM resistance may arise independently of predicted modes of action. Protein kinases have emerged as mediators of drug action and efficacy in malaria parasites; however, the link between top druggable Plasmodium kinases with LM, PQ, and AQ resistance remains unclear. Using LM, PQ, or AQ-resistant Plasmodium berghei parasites, we have evaluated the association of choline kinase (CK), pantothenate kinase 1 (PANK1), diacylglycerol kinase (DAGK), and phosphatidylinositol-4 kinase (PI4Kβ), and calcium-dependent protein kinase 1 (CDPK1) with LM, PQ, and AQ resistance in Plasmodium berghei ANKA. Methods We used in silico bioinformatics tools to identify ligand-binding motifs, active sites, and sequence conservation across the different parasites. We then used PCR and sequencing analysis to probe for single nucleotide polymorphisms (SNPs) within the predicted functional motifs in the CK, PANK1, DAGK, PI4Kβ, and CDPK1. Using qPCR analysis, we measured the mRNA amount of PANK1, DAGK, and PI4Kβ at trophozoites and schizonts stages. Results We reveal sequence conservation and unique ligand-binding motifs in the CK, PANK1, DAGK, PI4Kβ, and CDPK1 across malaria species. DAGK, PANK1, and PI4Kβ possessed nonsynonymous mutations; surprisingly, the mutations only occurred in the AQr parasites. PANK1 acquired Asn394His, while DAGK contained K270R and K292R mutations. PI4Kβ had Asp366Asn, Ser1367Arg, Tyr1394Asn and Asp1423Asn. We show downregulation of PANK1, DAGK, and PI4Kβ in the trophozoites but upregulation at the schizonts stages in the AQr parasites. Conclusions The selective acquisition of the mutations and the differential gene expression in AQ-resistant parasites may signify proteins under AQ pressure. The role of the mutations in the resistant parasites and their impact on drug responses require investigations using reverse genetics techniques in malaria parasites.

Impact of piperaquine resistance in Plasmodium falciparum on malaria treatment effectiveness in The Guianas: a descriptive epidemiological study

Plasmodium falciparum is an apicomplexan parasite responsible for lethal cases of malaria. According to WHO recommendations, P falciparum cases are treated with artemisinin-based combination therapy including dihydroartemisinin-piperaquine. However, the emergence of resistant parasites against dihydroartemisinin-piperaquine was reported in southeast Asia in 2008 and, a few years later, suspected in South America. To characterise resistance emergence, a treatment efficacy study was performed on the reported patients infected with P falciparum and treated with dihydroartemisinin-piperaquine in French Guiana (n=6, 2016-18). Contemporary isolates collected in French Guiana were genotyped for P falciparum chloroquine resistance transporter (pfCRT; n=845) and pfpm2 and pfpm3 copy number (n=231), phenotyped using the in vitro piperaquine survival assay (n=86), and analysed through genomic studies (n=50). Additional samples from five Amazonian countries and one outside the region were genotyped (n=1440). In field isolates, 40 (47%) of 86 (95% CI 35·9-57·1) were resistant to piperaquine in vitro; these phenotypes were more associated with pfCRTC350R (ie, Cys350Arg) and pfpm2 and pfpm3 amplifications (Dunn test, p<0·001). Those markers were also associated with dihydroartemisinin-piperaquine treatment failure (n=3 [50%] of 6). A high prevalence of piperaquine resistance markers was observed in Suriname in 19 (83%) of 35 isolates and in Guyana in 579 (73%) of 791 isolates. The pfCRTC350R mutation emerged before pfpm2 and pfpm3 amplification in a temporal sequence different from southeast Asia, and in the absence of artemisinin partial resistance, suggesting a geographically distinctive epistatic relationship between these genetic markers. The high prevalence of piperaquine resistance markers in parasite populations of the Guianas, and the risk of associated therapeutic failures calls for caution on dihydroartemisinin-piperaquine use in the region. Furthermore, greater attention should be given to potential differences in genotype to phenotype mapping across genetically distinct parasite populations from different continents. Pan American Health Organization and WHO, French Ministry for Research, European Commission, Santé publique France, Agence Nationale de la Recherche, Fundação de Amparo à Pesquisa do Estado do Amazonas, Ministry of Health of Brazil, Oswaldo Cruz Foundation, and National Institutes of Health. For the French and Portuguese translations of the abstract see Supplementary Materials section.

The first reported case of co-infection of imported hepatitis E and &lt;em&gt;Plasmodium falciparum&lt;/em&gt; malaria in Sri Lanka

Global travel and tourism, especially across tropical countries, may lead to importation of malaria and other infectious diseases into Sri Lanka. This case report describes the first co-infection of imported hepatitis E and Plasmodium falciparum malaria in a tourist diagnosed in Sri Lanka. The patient was initially diagnosed with uncomplicated P. falciparum malaria and was started on treatment with oral Artemisinin-based Combination Therapy (ACT). Deterioration of hepatic enzymes and hyperbilirubinaemia despite the rapid parasitological response to antimalarials led to further investigation and diagnosis of co-infecting hepatitis E in this patient. The importance of clinicians being vigilant on travel associated co-infections is highlighted to ensure early diagnosis and better patient management.

Baseline and recurrent exposure to the standard dose of artemisinin-based combination therapies (ACTs) induces oxidative stress and liver damage in mice (BALB/c)

BackgroundIn malaria-endemic countries, repeated intake of artemisinin-based combination therapies (ACTs) is rampant and driven by drug resistance, improper usage, and easy accessibility. Stress effects and potential liver toxicity due to the frequent therapeutic use of ACTs have not been extensively studied. Here, we investigated the effects of repeated treatment with standard doses of the commonly used ACTs artemether/lumefantrine (A/L) and artesunate-amodiaquine (A/A) on oxidative stress and liver function markers in male mice (BALB/c).MethodsForty Five mice were divided into three groups: control, A/L, and A/A. The drugs were administered three days in a row per week, and the regimen was repeated every two weeks for a total of six cycles. The levels of oxidative stress and liver function markers were measured in both plasma and liver tissue after initial (baseline) and repeated exposures for the second, third, and sixth cycles.ResultsExposure to A/L or A/A caused a significant (p < 0.001) increase in plasma malondialdehyde (MDA) levels after the first and repeated exposure periods. However, Hepatic MDA levels increased significantly (p < 0.01) only after the sixth exposure to A/A. Following either single or repeated exposure to A/L or A/A, plasma and liver glutathione peroxidase (GPx) and catalase (CAT) activities, plasma aspartate and alanine transaminase, alkaline phosphatase activity, and bilirubin levels increased, whereas total plasma protein levels decreased significantly (p < 0.001). Varying degrees of hepatocyte degeneration and blood vessel congestion were observed in liver tissues after a single or repeated treatment period.ConclusionIrrespective of single or repeated exposure to therapeutic doses of A/L or A/A, plasma oxidative stress and liver damage were observed. However, long-term repeated A/A exposure can led to hepatic stress. Compensatory processes involving GPx and CAT activities may help reduce the observed stress.

Variation in neutrophil levels and artemisinin-based combination therapy efficacy in West-Africa.

Polymorphonuclear neutrophils (PMN) are involved in pathogen clearance by phagocytosis. However, the role of PMNs in the efficacy of artemisinin-based combination therapy (ACT) is poorly understood. In a prospective longitudinal in vivo study, neutrophil rates were compared with malaria carriage after treatment with different ACTs: Artemether - lumefantrine (AL), Artesunate - amodiaquine (ASAQ), Dihydroartemisinin - piperaquine (DP) or Pyronaridine artesunate (PA). The study cases were classified as having neutropenia, normal neutrophil levels or neutrophilia depending on the level of neutrophils in the blood. This study included 3148 patients and was analyzed using R. On day 7, only four patients in the neutropenia group and treated with AL had a malaria positive blood smear based on microscopy. On day 28, the rate of recurrent parasitemia in the AL arm was significantly higher in neutropenia patients (50.9%) than in patients with normal rates of neutrophils (43.1%) or in those with neutrophilia (6.0%) (p < 0.001). In ASAQ arm, the rate of recurrent Plasmodium falciparum parasitemia was 58.8% in the neutropenia group versus 29.4% in patients with normal rates of neutrophils and 11.8% in patients with neutrophilia (p < 0.001). No patient treated with DP with normal neutrophil counts or neutrophilia was carrying malaria parasites on day 28. Among the 15 patients with parasitemia on day 28 in the PA arm, 11 (73.33%) had neutropenia while 4 (26.67%) had a normal neutrophil count (p < 0.001). Patients with neutropenia had higher rates of recurrent P. falciparum parasitemia after ACT.

Reporting the impact of artemisinin resistance: Molecular surveillance of pfK13 and pfEXO mutations in Plasmodium falciparum in Southern provinces of Vietnam

Background: Malaria, mainly caused by Plasmodium falciparum, is a major global health concern. In Vietnam, resistance to artemisinin-based combination therapies (ACTs) is rising, jeopardizing malaria control efforts. This study focuses on mutations in the pfK13 and pfEXO genes, particularly the E415G mutation, in Southern Vietnam.&#x0D; Methods: The study involved 421 patients across two cohorts. The first, with 63 patients from Binh Phuoc and Dak Nong, had uncomplicated P. falciparum malaria and were part of the Therapeutic Efficacy Studies (TES), treated according to WHO guidelines (2009). The second cohort, comprising 358 patients from the Central Highlands, aimed to assess mutation frequency in genes linked to artemisinin resistance. Molecular marker analysis, including Sanger sequencing for pfK13 and ARMS-PCR for E415G in pfEXO, was conducted. The study also examined the association of these mutations with Day 3 parasitemia and treatment outcomes using Dihydroartemisinin-Piperaquine (DHA-PPQ).&#x0D; Results: Most cases showed mutations in pfK13, linked to delayed parasite clearance and higher treatment failure, indicating pfK13 as a key marker for artemisinin resistance. The E415G mutation in pfEXO was common but not significantly associated with resistance or treatment outcomes, though there was a tendency towards increased treatment failure among these patients. Conclusion: Our study implies the critical role of the C580Y mutation in the pfK13 gene in artemisinin resistance and its impact on the efficacy of ACTs in Vietnam. The findings highlight the necessity for monitoring these mutations as molecular markers for drug resistance and call for the exploration of alternative treatment strategies in the face of evolving antimalarial drug resistance. This study contributes valuable insights to the molecular epidemiology of malaria in Southern provinces in Vietnam and emphasizes the urgency of addressing artemisinin resistance in the global fight against malaria.&#x0D; Key words: pfK13, E415G , artemisinin resistance, P. falciparum, malaria.