A clinical and molecular study of artesunate + sulphadoxine-pyrimethamine in three districts of central and eastern India

Abstract

Background: Artesunate + sulphadoxine-pyrimethamine (AS + SP) is recommended throughout India as the first-line treatment for uncomplicated falciparum malaria. Due to the presence of several eco-epidemiological zones of malaria and variable drug pressure, it is necessary to evaluate the efficacy of this combination in different regions of India. The objective of this study was to use clinical and molecular methods to monitor the efficacy of AS + SP in three diverse sites.

Methods: The study was undertaken in three high endemic sites of central and eastern India. Patients with uncomplicated falciparum malaria were enrolled and followed for 28 days. Molecular genotyping was conducted for merozoite surface protein (msp1 and msp2) to differentiate between re-infection and recrudescence and for the dhfr and dhps genes to monitor antifolate drug resistance.

Results: In all, 149 patients were enrolled at the three sites. The crude cure rates were 95.9%, 100%, and 100% in Ranchi, Keonjhar, and West Garo Hills respectively. PCR-corrected cure rates were 100% at all sites. In dhfr, 27% of isolates had triple mutations, while 46% isolates were double-mutants. The most prevalent mutation was S108N followed by C59R. 164 L mutation was observed in 43/126 (34%) isolates. In dhps, most (76%) of the isolates were wild-type. Only 2.5% (2/80) isolates showed double mutation. dhfr-dhps two locus mutation were observed in 16% (13/80) isolates. Parasite clearance time was not related with antifolate mutations.

Conclusions: AS + SP combination therapy remained effective against falciparum malaria despite common mutations promoting resistance to antifolate drugs. Although the prevalence of double and triple mutations in dhfr was high, the prevalence of dhfr-dhps two locus mutations were low. Even isolates with dhfr triple and dhfr-dhps two locus mutations achieved adequate clinical and parasitological response.

Figure 1

Selected study sites for AS + SP therapeutic efficacy studies, Keonjhar (Odisha), Ranchi (Jharkhand) and West Garo Hills (Meghalaya) and total mutations in dhfr and dhps gene, 2007 and 2010. Abbreviations: SM, single mutation, DM, double mutation, TM, triple mutation, QM, quadruple mutation.

Figure 2

Flow chart of patients enrolled for AS + SP treatment at Keonjhar (Odisha), Ranchi (Jharkhand) and West Garo Hills (Meghalaya), India, 2007 and 2010. Abbreviations: Pv, Plasmodium vivax; LTF, late treatment failure.