Aline Uwimana1, Noella Umulisa2, Meera Venkatesan3, Samaly S Svigel4, Zhiyong Zhou4, Tharcisse Munyaneza5, Rafiki M Habimana5, Anicet Rucogoza5, Leah F Moriarty6, Ryan Sandford7, Emily Piercefield8, Ira Goldman4, Bryan Ezema4, Eldin Talundzic4, M Andreína Pacheco9, Ananias A Escalante9, Daniel Ngamije10, Jean-Louis N Mangala1, Michee Kabera1, Kaendi Munguti11, Monique Murindahabi12, William Brieger13, Clarisse Musanabaganwa14, Leon Mutesa15, Venkatachalam Udhayakumar4, Aimable Mbituyumuremyi1, Eric S Halsey6, Naomi W Lucchi16. 1. Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda. 2. Maternal and Child Survival Program, Jhpiego, Kigali, Rwanda; PMI Impact Malaria, Kigali, Rwanda. 3. US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA. 4. Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States. 5. National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda. 6. Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States; US President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA. 7. US Peace Corps, Kigali, Rwanda. 8. US President's Malaria Initiative, US Centers for Disease Control and Prevention, Kigali, Rwanda. 9. Biology Department, Institute of Genomics and Evolutionary Medicine, Temple University Philadelphia, PA, USA. 10. Ministry of Health, Kigali, Rwanda. 11. US President's Malaria Initiative, US Agency for International Development, Kigali, Rwanda. 12. Roll Back Malaria, West and Central Africa National Malaria Control Programme, Bobo-Dioulasso, Burkina Faso. 13. Bloomberg School of Public Health, Department of International Health, Johns Hopkins University, Baltimore, MD, USA. 14. Medical Research Center, Rwanda Biomedical Centre, Kigali, Rwanda. 15. Centre for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. 16. Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States; US President's Malaria Initiative, US Centers for Disease Control and Prevention, Kigali, Rwanda. Electronic address: nlucchi@cdc.gov.
Abstract
BACKGROUND: Partial artemisinin resistance is suspected if delayed parasite clearance (ie, persistence of parasitaemia on day 3 after treatment initiation) is observed. Validated markers of artemisinin partial resistance in southeast Asia, Plasmodium falciparum kelch13 (Pfkelch13) R561H and P574L, have been reported in Rwanda but no association with parasite clearance has been observed. We aimed to establish the efficacy of artemether-lumefantrine and genetic characterisation of Pfkelch13 alleles and their association with treatment outcomes. METHODS: This open-label, single-arm, multicentre, therapeutic efficacy study was done in 2018 in three Rwandan sites: Masaka, Rukara, and Bugarama. Children aged 6-59 months with P falciparum monoinfection and fever were eligible and treated with a 3-day course of artemether-lumefantrine. Treatment response was monitored for 28 days using weekly microscopy screenings of blood samples for P falciparum. Mutations in Pfkelch13 and P falciparum multidrug resistance-1 (Pfmdr1) genes were characterised in parasites collected from enrolled participants. Analysis of flanking microsatellites surrounding Pfkelch13 was done to define the origins of the R561H mutations. The primary endpoint was PCR-corrected parasitological cure on day 28, as per WHO protocol. FINDINGS: 228 participants were enrolled and 224 (98·2%) reached the study endpoint. PCR-corrected efficacies were 97·0% (95% CI 88-100) in Masaka, 93·8% (85-98) in Rukara, and 97·2% (91-100) in Bugarama. Pfkelch13 R561H mutations were present in 28 (13%) of 218 pre-treatment samples and P574L mutations were present in two (1%) pre-treatment samples. 217 (90%) of the 240 Pfmdr1 haplotypes observed in the pretreatment samples, had either the NFD (N86Y, Y184F, D1246Y) or NYD haplotype. Eight (16%) of 51 participants in Masaka and 12 (15%) of 82 participants in Rukara were microscopically positive 3 days after treatment initiation, which was associated with pre-treatment presence of Pfkelch13 R561H in Masaka (p=0·0005). Genetic analysis of Pfkelch13 R561H mutations suggest their common ancestry and local origin in Rwanda. INTERPRETATION: We confirm evidence of emerging artemisinin partial resistance in Rwanda. Although artemether-lumefantrine remains efficacious, vigilance for decreasing efficacy, further characterisation of artemisinin partial resistance, and evaluation of additional antimalarials in Rwanda should be considered. FUNDING: The US President's Malaria Initiative. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.
BACKGROUND: Partial artemisinin resistance is suspected if delayed parasite clearance (ie, persistence of parasitaemia on day 3 after treatment initiation) is observed. Validated markers of artemisinin partial resistance in southeast Asia, Plasmodium falciparum kelch13 (Pfkelch13) R561H and P574L, have been reported in Rwanda but no association with parasite clearance has been observed. We aimed to establish the efficacy of artemether-lumefantrine and genetic characterisation of Pfkelch13 alleles and their association with treatment outcomes. METHODS: This open-label, single-arm, multicentre, therapeutic efficacy study was done in 2018 in three Rwandan sites: Masaka, Rukara, and Bugarama. Children aged 6-59 months with P falciparum monoinfection and fever were eligible and treated with a 3-day course of artemether-lumefantrine. Treatment response was monitored for 28 days using weekly microscopy screenings of blood samples for P falciparum. Mutations in Pfkelch13 and P falciparum multidrug resistance-1 (Pfmdr1) genes were characterised in parasites collected from enrolled participants. Analysis of flanking microsatellites surrounding Pfkelch13 was done to define the origins of the R561H mutations. The primary endpoint was PCR-corrected parasitological cure on day 28, as per WHO protocol. FINDINGS: 228 participants were enrolled and 224 (98·2%) reached the study endpoint. PCR-corrected efficacies were 97·0% (95% CI 88-100) in Masaka, 93·8% (85-98) in Rukara, and 97·2% (91-100) in Bugarama. Pfkelch13 R561H mutations were present in 28 (13%) of 218 pre-treatment samples and P574L mutations were present in two (1%) pre-treatment samples. 217 (90%) of the 240 Pfmdr1 haplotypes observed in the pretreatment samples, had either the NFD (N86Y, Y184F, D1246Y) or NYD haplotype. Eight (16%) of 51 participants in Masaka and 12 (15%) of 82 participants in Rukara were microscopically positive 3 days after treatment initiation, which was associated with pre-treatment presence of Pfkelch13 R561H in Masaka (p=0·0005). Genetic analysis of Pfkelch13 R561H mutations suggest their common ancestry and local origin in Rwanda. INTERPRETATION: We confirm evidence of emerging artemisinin partial resistance in Rwanda. Although artemether-lumefantrine remains efficacious, vigilance for decreasing efficacy, further characterisation of artemisinin partial resistance, and evaluation of additional antimalarials in Rwanda should be considered. FUNDING: The US President's Malaria Initiative. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.
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