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Plasmodium Falciparum Artemisinin Resistance Monitoring in Sabah, Malaysia: in Vivo Therapeutic Efcacy and Kelch13 Molecular Marker Surveillance Matthew J

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Plasmodium Falciparum Artemisinin Resistance Monitoring in Sabah, Malaysia: in Vivo Therapeutic Efcacy and Kelch13 Molecular Marker Surveillance Matthew J Grigg et al. Malar J (2018) 17:463 https://doi.org/10.1186/s12936-018-2593-x Malaria Journal RESEARCH Open Access Plasmodium falciparum artemisinin resistance monitoring in Sabah, Malaysia: in vivo therapeutic efcacy and kelch13 molecular marker surveillance Matthew J. Grigg1,2* , Timothy William2,3,4, Kim A. Piera1,2, Giri S. Rajahram2,4,6, Jenarun Jelip7, Ammar Aziz1, Jayaram Menon4,6, Jutta Marfurt1, Ric N. Price1,8, Sarah Auburn1, Bridget E. Barber1,2,5, Tsin W. Yeo1,2,9,10† and Nicholas M. Anstey1,2† Abstract Background: Spreading Plasmodium falciparum artemisinin drug resistance threatens global malaria public health gains. Limited data exist to defne the extent of P. falciparum artemisinin resistance southeast of the Greater Mekong region in Malaysia. Methods: A clinical efcacy study of oral artesunate (total target dose 12 mg/kg) daily for 3 days was conducted in patients with uncomplicated falciparum malaria and a parasite count < 100,000/µL admitted to 3 adjacent district hos- pitals in Sabah, East Malaysia. On day 3 and 4 all patients were administered split dose mefoquine (total dose 25 mg/ kg) and followed for 28 days. Twenty-one kelch13 polymorphisms associated with P. falciparum artemisinin resistance were also evaluated in P. falciparum isolates collected from patients presenting to health facilities predominantly within the tertiary referral area of western Sabah between 2012 and 2016. Results: In total, 49 patients were enrolled and treated with oral artesunate. 90% (44/49) of patients had cleared their parasitaemia by 48 h and 100% (49/49) within 72 h. The geometric mean parasite count at presentation was 9463/ µL (95% CI 6757–13,254), with a median time to 50% parasite clearance of 4.3 h (IQR 2.0–8.4). There were 3/45 (7%) patients with a parasite clearance slope half-life of 5 h. All 278 P. falciparum isolates evaluated were wild-type for kelch13 markers. ≥ Conclusion: There is no suspected or confrmed evidence of endemic artemisinin-resistant P. falciparum in this pre-elimination setting in Sabah, Malaysia. Current guidelines recommending frst-line treatment with ACT remain appropriate for uncomplicated malaria in Sabah, Malaysia. Ongoing surveillance is needed southeast of the Greater Mekong sub-region. Keywords: Plasmodium falciparum, Malaria, kelch, K13, Artemisinin-resistance Background elimination eforts [1, 2]. To date public health concerns Te spread of Plasmodium falciparum artemisinin have focused on the signifcant danger of artemisinin- resistance from Southeast Asia threatens global malaria resistant P. falciparum spreading westwards from Greater Mekong region into the Indian subcontinent and onwards to sub-Saharan Africa, where the majority of the *Correspondence: [email protected] global burden of disease exists [3, 4]. However, monitor- †Tsin W. Yeo and Nicholas M. Anstey contributed equally to this work 2 Infectious Diseases Society Sabah-Menzies School of Health Research ing for the south-eastward spread of artemisinin resist- Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia ance to other endemic countries in Southeast Asia, many Full list of author information is available at the end of the article of which are approaching elimination of P. falciparum © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat​iveco​mmons​.org/ publi​cdoma​in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Grigg et al. Malar J (2018) 17:463 Page 2 of 8 and other human-only Plasmodium species, is also essen- all microscopy positive patients [13, 14]; only those with tial to ensure that the signifcant public health gains in P. falciparum confrmed infections were included in the this region are not lost [3]. fnal analysis. Te discovery of molecular markers associated with P. Patients received oral artesunate alone daily for 3 days falciparum artemisinin resistance on the kelch gene on [target dose 4 mg/kg, using 75 mg/5 kg dose-weight chromosome 13 (kelch13) [5] has provided an important banding increments (Table 1)] [1], followed by oral mefo- tool for efective molecular surveillance [1, 2, 6], which quine (target dose 25 mg/kg, split in 2 doses of 15 mg/ can help defne the geographical spread of resistant para- kg and 10 mg/kg) over 2 subsequent days (Artequin ®, sites, and guide targeted malaria public health activities. Novartis, Switzerland). Demographic, clinical and labo- Early detection of P. falciparum artemisinin resistance ratory data were collected at presentation and then daily also facilitates optimal treatment strategies to protect the during hospital admission. Blood slides for microscopy concurrent development of resistance in longer-acting were obtained 6-hourly until a minimum of 2 consecu- artemisinin-based combination therapy (ACT) partner tive negative results were recorded. Whole blood samples drugs, such as piperaquine [7–9]. were collected at enrolment, then at 24, 48, and 72 h after In Malaysia, the reported number of falciparum treatment, and at fnal follow-up 28 days after enrolment. malaria cases has decreased from around 5000 in 2010 to less than 20 in 2017; with progress on track to meet the kelch13 molecular surveillance national WHO elimination goal for human-only malaria Molecular markers previously associated with P. fal- by 2020 [3]. Malaysia borders Tailand where arte- ciparum artemisinin resistance were evaluated using misinin-resistant P. falciparum is established. At the time PCR to detect 21 single nucleotide polymorphisms of study design, no previous studies had evaluated the on the kelch13 gene (see Additional fle 1), as previ- presence of artemisinin resistance in Malaysia, particu- ously described [5, 15]. Additional patients evaluated larly in East Malaysia on the island of Borneo where the for kelch13 mutations included those with falciparum majority of P. falciparum transmission occurs [10, 11]. To malaria excluded from the clinical trial, but who were determine whether artemisinin-resistant P. falciparum enrolled in a concurrent clinical malaria study at the was present in Sabah, Eastern Malaysia, a clinical efcacy same sites and during the same study period [16], as well study of oral artesunate was conducted with complemen- as patients with falciparum malaria enrolled in an ongo- tary parasite molecular studies to genotype kelch13 poly- ing prospective malaria study at the state tertiary referral morphisms associated with artemisinin resistance. hospital in Kota Kinabalu from 2010 to 2016 [17]. Data were entered into Epidata (version 3.1) and ana- Methods lysed using Stata (version 12). Microscopic asexual para- Clinical efcacy study sitaemia and gametocytaemia were calculated from thick Patients were enrolled from October 2012 to February blood smears [18]. Best-ft linear or tobit regression mod- 2016 at 3 adjacent district hospital sites at Kudat, Kota els were used to estimate the curve of loge parasite counts Marudu and Pitas in northwest Sabah, Malaysia. Patients over time [19]. weighing more than 10 kg and up to 65 years of age were enrolled if they had acute uncomplicated malaria, con- Results frmed by positive blood smear for asexual forms of P. Clinical efcacy study falciparum on hospital microscopy, with a parasite count 852 patients with malaria were admitted to the study between 1000 and 100,000/µL, a positive P. falciparum site hospitals, of whom 59 patients with P. falciparum histidine-rich protein 2 (Pf-HRP2) result on malaria rapid on screening microscopy were enrolled into the study diagnostic test (CareStart™ Pf/Pan, Access Bio, USA), a (Fig. 1). Of these patients, 49 with P. falciparum infection documented temperature > 37.5 °C or a history of fever met the study inclusion and exclusion criteria and were in the last 48 h. Written informed consent was obtained included in the fnal analysis (Table 2). Te median age in all patients, including from a relevant parent/guard- was 18 (IQR 11–31), with 14 (29%) children aged 12 years ian for those < 18 years of age. Patients were excluded if or less. Tere were 7 (14%) patients with a previous self- there were any WHO-defned clinical or laboratory signs reported history of malaria requiring hospital admission, of severe malaria [12], or they had a haemoglobin con- and the median duration of preceding fever was 5 days. centration at presentation < 7 g/dL, had received arte- Te most common presenting symptom was headache misinin-containing therapy in the previous 7 days, had a (92%), followed by chills or rigors (67%), vomiting (49%), concurrent acute illness was present, had a previous sple- and muscle and joint pain (45%). At presentation, the nectomy, or, for females, if they were pregnant or breast- geometric mean parasite count was 9463/µL (95% CI feeding. Subsequent diagnostic PCR was conducted for 6757–13,254), and 24 (49%) patients had anaemia (using Grigg et al. Malar J (2018) 17:463 Page 3 of 8 Table 1 Oral artesunate dose-bodyweight banding bodyweight was 11.8 mg/kg (SD ± 0.9), with no statisti- Dose Bodyweight Total dose Number Dose (mg)/ cally signifcant diference demonstrated in the fnal total band (kg) (mg) of patients bodyweight (kg) dose per bodyweight received between those in diferent (mean, SD) dose-weight bands (Table 1). 1 10–16 150 4 11.1 (2.6) At 48 h after treatment 44/49 (90%; CI 95 78–97) of 2 17–22 225 5 11.6 (1.0) patients were negative for parasites microscopically 3 23–28 300 3 11.8 (1.1) on blood smear.
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