Surveillance of genetic markers associated with Plasmodium falciparum resistance to artemisinin-based combination therapy in Pakistan, 2018-2019

Abstract

Background: The spread of artemisinin resistance in the Greater Mekong Subregion of Southeast Asia poses a significant threat for current anti-malarial treatment guidelines globally. The aim of this study was to assess the current prevalence of molecular markers of drug resistance in Plasmodium falciparum in the four provinces with the highest malaria burden in Pakistan, after introducing artemether-lumefantrine as first line treatment in 2017.Methods: Samples were collected during routine malaria surveillance in Punjab, Sindh, Baluchistan, and Khyber Pakhtunkhwa provinces of Pakistan between January 2018 and February 2019. P. falciparum infections were confirmed by rapid diagnostic test or microscopy. P. falciparum positive isolates (n = 179) were screened by Sanger sequencing for single nucleotide polymorphisms (SNPs) in the P. falciparum kelch 13 (pfk13) propeller domain and in P. falciparum coronin (pfcoronin). SNPs in P. falciparum multidrug resistance 1 (pfmdr1) N86Y, Y184F, D1246Y and P. falciparum chloroquine resistance transporter (pfcrt) K76T were genotyped by PCR-restriction fragment length polymorphism. Results: No artemisinin resistance associated SNPs were identified in the pfk13 propeller domain or in pfcoronin. The pfmdr1 N86, 184F, D1246 and pfcrt K76 alleles associated with reduced lumefantrine sensitivity were present in 83.8% (150/179), 16.9% (29/172), 100.0% (173/173), and 8.4% (15/179) of all infections, respectively. The chloroquine resistance associated pfcrt 76T allele was present in 98.3% (176/179) of infections.Conclusion: This study provides an update on the current prevalence of molecular markers associated with reduced sensitivity to artemether and/or lumefantrine in P. falciparum, including a first baseline assessment of polymorphisms in pfcoronin. No mutations associated with artemisinin resistance were observed in pfk13 or pfcoronin. However, the prevalence of the pfmdr1 N86 and D1246 alleles, that have been associated with decreased susceptibility to lumefantrine, remain high. Although clinical and molecular data suggest that the current malaria treatment guideline for P. falciparum are presently effective in Pakistan, close monitoring for artemisinin and lumefantrine resistance will be critical to ensure early detection and enhanced containment of emerging ACT resistance spreading across from Southeast Asia.

Surveillance of molecular markers of antimalarial drug resistance in Plasmodium falciparum and Plasmodium vivax in Federally Administered Tribal Area (FATA), Pakistan

“…Similarly, a study conducted in Pakistan in 2013 found the same results 8 . A survey of clinical isolates collected from all over Pakistan in 2018 found that 98.3% of the country had the CQR 15 , and comparable results have been reported from adjacent countries 26 .…”

“…Molecular markers of drug resistance against SP have been reported in a few studies on blood samples representing different Pakistan provinces except for the Federally Administered Tribal Area (FATA) in Pakistan 12,13 . In in vitro/in vivo investigations have revealed the artemisinin resistance along the Thailand-Cambodia border, in Vietnam, Myanmar and other Southeast Asian countries 14 but it is still an effective antimalarial drug in Pakistan 12,15 .…”

Surveillance of molecular markers of antimalarial drug resistance in Plasmodium falciparum and Plasmodium vivax in Federally Administered Tribal Area (FATA), Pakistan

“…Similarly, a study conducted in Pakistan in 2013 found the same results 8 . A survey of clinical isolates collected from all over Pakistan in 2018 found that 98.3% of the country had the CQR 15 , and comparable results have been reported from adjacent countries 26 .…”

“…Molecular markers of drug resistance against SP have been reported in a few studies on blood samples representing different Pakistan provinces except for the Federally Administered Tribal Area (FATA) in Pakistan 12,13 . In in vitro/in vivo investigations have revealed the artemisinin resistance along the Thailand-Cambodia border, in Vietnam, Myanmar and other Southeast Asian countries 14 but it is still an effective antimalarial drug in Pakistan 12,15 .…”