TRANSACTIONS OFTHEROYALSOCIETYOFTROPICALMEDICINEANDHYGIENE(2002)96,664-669

High Plasmodium fa/ciparum resistance to chloroquine and sulfadoxine-

pyrimethamine in Harper, Liberia: results in vivo and analysis of point
mutations

F. Checchi’, R. Durand’, S. Balkan’, B. T. Vonhm3, J. Z. Kollie’, P. Biberson’, E. Baron’, J. Le Bras2 and

J.-P. Guthmann4 ‘Mt?decins Suns Front&es, 8 rue Saint-Sub& 75011 Park, France; ‘Laboratoire de Parasitologie-
Mycologic, Hspital Bichat-Claude Bernard, 46 rue Hem-i Huchard, 75877 Park, France; 3Malan’a Control Program,
Ministry of Health and Social Welfare, Monrovia, Liberia; 4Epicentre, 8 rue Saint-Sabin, 75011 Park, France

Abstract
In Liberia, little information is available on the efficacy of antimalarials against Plasmodium falciparum
malaria. We measured parasitological resistance to chloroquine and sulfadoxine-pyrimethamine (SP) in
Harper, south-west Liberia in a 28-d study in vivo. A total of 50 patients completed follow-up in the
chloroquine group, and 66 in the SP group. The chloroquine failure rate was 74.0% (95% confidence
interval [95% CI] 59.7-85.4%) after 14 d of follow-up and 84.0% (95% CI 70.9-92.8%) after 28 d (no
polymerase chain reaction [PCR] analysis was performed to detect reinfections in this group). In the SP
group, the failure rate was 48.5% (95% CI 36.2-61.0%) after 14 d and 69.7% (95% CI 57.1-80.4%)
after 28 d, readjusted to 51.5% (95% CI 38.9-64.0%) after taking into account reinfections detected by
PCR. Genomic analysis of parasite isolates was also performed to look for point mutations associated
with resistance. Genotyping of parasite isolates revealed that all carried chloroquine-resistant K-76T
mutations at gene pfcrt, whereas the triple mutation (S108N, N511, C59R) at dhfr and the A437G
mutation at dhps, both associated with resistance to SP, were present in 84% and 79% of pretreatment
isolates respectively. These results seriously question the continued use of chloroquine and SP in Harper
and highlight the urgency of making alternative antimalarial therapies available. Our study confirms that
resistance to chloroquine may be high in Liberia and yields hitherto missing information on SP.
Keywords: malaria, Plasmodium falciparum, chemotherapy, chloroquine, sulfadoxine-pyrimethamine, resistance, pfcrt,
dhfr dhps, Liberia

Introduction only 5 studies conducted from 1993 to 1999, reporting

Every year in Africa according to a conservative
estimate approximately 200 million cases of PZasmo-
dium falcip%rum malaria occur, of which at least one
million result in death (SNOW et al.. 1999). This
problem is further aggravated by widespiead resistance
of l? falciparum to chloroquine (BLOLAND, 2001). In
spite of this, the drug is still the recommended first-line
therapy almost everywhere in Africa. Experience from
south-east Asia shows that resistance to sulfadoxine-
pyrimethamine (SP) rises quickly where it is introduced
as monotherapy and reports of falling SF cure rates are
accumulating from East African sites where the drug
has replaced chloroquine (R~NN et al., 1996; STAEDKE
et al., 2001). A scenario may thus be unfolding in
which entire regions of Africa are left without efflca-
cious and affordable therapies for malaria (WHITE et
al., 1999).
The principal tool to measure resistance to antima-
larials remains the assessment of therapeutic efficacy in
vivo. Conclusions of studies in vivo may, however, be
re-enforced by related genomic analyses of DNA point
mutations associated with l? falciparum resistance to
antimalarials. Recently, chloroquine resistance in vivo
has been conclusively linked to the K-76T mutation in
the pfcrt gene (WELLEMS & PLOWE, 2001). Similarly,
many studies report that point mutations in the dhfr
gene are linked to pyrimethamine resistance (DOUMBO
et al., 2000) and that SP treatment failure in vivo is
associated with the simultaneous occurrence of such
mutations, notablv at dhfr codons 5 1, 59, and 108
(NAGESH~ et al, “2001). “Point mutatidns &-I the dhps
gene have also been associated with sulfadoxine resis-
tance in vitro (TRIGLIA et al., 1997).
In Liberia, chloroquine and SP are respectively the
first- and second-line therapies for malaria. Surveil-
lance of antimalarial resistance has been scanty with
Address for correspondence: Jean-Paul Guthmann, Epicentre,
8 rue Saint-Sabin, 75011 Paris, France; phone +33 1 40 21 28
48, fax +33 1 40 21 28 03,
e-mail jguthmann@epicentre.msf.org
chloroquine failure rates in vivo between 5% and 38%
(B. Vonhm et al., unpublished report). Moreover, to
our knowledge no studies of resistance to SP have ever
been conducted in Liberia.
Since 1997, Medecins Sans Frontihes (MSF) has
been supporting a hospital in the south-eastern Liber-
ian city of Harper, the only secondary health care
facility for a catchment area of some 90000 people.
According to MSF records, malaria is the most impor-
tant health problem in Harper, accounting between
1998 and 2000 for about one-third of all consultations
(400-450 cases per month, diagnosed mostly on clin-
ical signs), and a similar proportion of admissions and
hospital deaths. Among children aged < 5 years, the
disease is responsible for almost half of cases and
deaths. Transmission (represented by monthly out-
patient consultations) seems stable year-round and l?
falciparum is responsible for nearly all infections (97%)
according to hospital laboratory records.
Results of 2 14-d efficacy studies in vivo conducted
in areas surrounding Harper suggested that antimalar-
ial efficacy was declining in this region. In Pleebo
district (north of Harper) chloroquine resistance was
23% (B. Vonhm et al., unpublished report) and, in
Tabou district of the Ivory Coast (an area across the
border to which Harper residents fled during the
1989-96 Liberian civil war), 45% resistance to chloro-
quine and 6% resistance to SP were found (VILLADARY
et al. 1997). These results, combined with the huge
burden of P: falciparum malaria on site, prompted us to
carry out a &dy&irz viva of parasitological reiistance to
chloroauine and SP in Harrier. Genomic analvsis of
parasiti isolates collected duiing the study in v&o was
also performed, in which polymerase chain reaction
(PCI?) genotyping methods-w&e employed to look for
markers of resistance to both chloroauine (K-76T pfcrt
mutation) and SP (S108N, N511, ana C59kmuta&ns
of dhfr and the A437G mutation of dhps). Study pa-
tients were recruited from the outpatient departments
of 11 Dossen Memorial Hospital and Sacred Heart
Cl& in Harper. The study was approved and sup-
norted bv the Liberian Ministry of Health and Social
iWelfare. .
PLASMODIUM FALCIPARUM DRUG RESISTANCE
Materials and Methods
Sample size
For samnle size determination in the study in vivo, a
resistance ;o chloroquine of 40% was hypothesized,
with a desired urecision of 10%. Similarlv. 10% resis-
tance to SP was estimated, to be detected with 7.5%
precision. At a significance level of 0.05 and with a
power of 0.80, we required 93 inclusions in the chloro-
quine group and 62 in the SP group. Including a 10%
loss to follow-up, a target of 171 inclusions was thus
set.
Enrolment procedures
Our methodology in vivo was an adaptation of the
WHO (1996) protocol for the assessment of therapeu-
tic efficacy of antimalarial drugs in areas of intense
transmission. Accordingly, clinicians were asked to
refer to the study all children aged 6-59 months with
clinically suspected malaria. Referrals were assessed by
a study clinician and sent to the laboratory, where thick
and thin blood films were obtained. Children were
eligible for enrolment if they met the following inclu-
sion criteria: (i) age 6-59 months; (ii) fever (axillary
temperature 2 37.5 “C) or history of fever in the past
24 h; (iii) l? falciparum monoinfection with asexual
parasitaemia 1OOO- 100 OOO/pL; and (iv) residence less
than 1 h walking distance from the hospital. Exclusion
criteria were: (i)-danger signs or signs of severe malaria
(WHO. 1996): (ii) nresence of concomitant febrile
illnesses; (iii) serious underlying condition; (iv) history
of allergy to either chloroquine or SF’; and (v) any
antimalarial intake in the past 7 d according to the
parent or guardian’s account. Written informed con-
sent was obtained from parents and guardians of all
children enrolled. Allocation to either the chloroquine
or SP treatment group was randomized.
Treatment and follow-up
Children in the chloroquine group received
25 mg/kg bodyweight of oral chloroquine (I 50 mg base
tablets, Laboratoires Creat, Vernouillet, France) over
3 d (10 mg/kg on day 0, 10 mg/kg on day 1, and
5 mg/kg on day 2). Patients in the SP group received a
single dose of oral SP tablets (500 mg sulfadoxi-
ne + 25 mg pyrimethamine, Fansida@, Laboratoires
Creat) on day 0 (at 1.25 mg/kg bodyweight pyrimetha-
mine). Dosages were expressed as fractions of tablets.
Study drug administration on days 0, 1, and 2 occurred
on site and was directly observed for 30 min. Tablets
were crushed in small amounts of water if needed, and
readministered in case of vomiting after a 30-min rest
period.
After the treatment period, all parents and guardians
were asked to bring their children for follow-up visits
on day 3, day 7, day 14, and day 28 (or any other day if
the child’s condition was of concern). At each visit, a
clinical assessment was made by the nurse clinician and
thick and thin films were obtained. Children who met
the definitions of treatment failure received immediate
rescue treatment: this consisted of SP 1.25 m&kg
for chloroquine failures, and quinine hydroch&ide
10 mg/kg/8 h for 5 to 7 d for SP failures. Defaulters
were traced by a home visitor and encouraged to return
as soon as possible: if they did not return after 2 home
visits, they were considered lost to follow-up. Patients
were withdrawn from the study for any of the following
reasons: (i) failure to take any study drug dose; (ii)
vomiting any study dose twice; (iii) severe allergic
reaction to the study drug; (iv) onset of a non-malaria
febrile illness during follow-un; (v) self-medication with
antimalarials during follow-upf ‘and (vi) decision of
parent/guardian.
Therapeutic outcomes
Patients were classified as early treatment failure
(ETF) if they met the following criteria: (i) progression
665
to severe malaria on days 1, 2, or 3; (ii) parasitaemia on
dav 2 higher than on dav 0 in the nresence of fever; (iii)
any parisitaemia in thhpresence-of fever on day 3: or
(iv) day 3 parasitaemia 2 25% of the day 0 count,
irrespective of fever. Patients were classified as late
treatment failure (LTF) if any parasitaemia was ob-
served after the day 3 visit, irrespective of symptoms.
All others were classified as adequate treatment re-
sponse (ATR), provided that they completed per-pro-
tocol follow-up.
Laboratory procedures
Thick and thin films were Giemsa-stained (10%
dilution for 13 min) and asexual counts were obtained
on the thick smear bv counting the number of tro-
phozoites against 206 leucocytes (white blood cells
[WBC]), assuming a normal blood level of 8000
WBC/uL. A sample of thick slides was re-read by an
experienced technician. Capillary blood samples- for
genomic analysis were collected on Whatmann No. 3
filter-paper in 50 + aliquots, dried, and stored in the
dark in sealed bags at room temperature. Parasite DNA
was extracted using Chelex-100 Resin (Bio-Rad La-
boratories, Hercules, CA, USA) as described elsewhere
(PLOWE et al., 1995).
PCR genotyping for detection of reinfections
Capillary blood samples were analysed to distinguish
recrudescences from reinfections according to a meth-
od previously described (SNOUNOU et al., 1999). A
polymorphic region of the l? falciparum msp2 gene was
amplified by nested PCR and amplification products
were run on a 2% agarose gel. The band profiles of
paired pretreatment and failure-day samples were then
compared. Paired samples with different band profiles
were classified as reinfections and similar band profiles
were classified as a recrudescence. Similar profiles with
additional or missing bands in either sample were also
classified as a recrudescence: the difference in the num-
ber of bands was explained by selection of previously
undetected clones, presence of a novel infection super-
imposed on the recrudescent one or disappearance of
drug-sensitive clones present in the pretreatment infec-
tion. For logistical reasons PCR genotyping could not
be performed in the chloroquine group.
Analysis of resistance markers
The amplification of a portion of the pfcrt gene
spanning codon 76 was performed as previously de-
scribed (DURAND et aZ., 2001). Codon 108 of the dlzfi
gene was determined by PCR and molecular beacons
as nreviouslv described (DURAND et al.. 2000). A 116-
bp-DNA fragment spanning codons 51 and 59 of the
dhfi gene and a 525&p DNA fragment spanning codon
437 of the dhas gene were also amnlified. The se-
quences of prime& used were as follows: dhfi 51, 59
5’-CACATTTAGAGGTCTAGGAAATAAAGGA-3’
(sense) and 5’-TCAATTTTTCATATTTTGATT
CATTCAC-3’ (antisense), dhps 437 5’-TTTGTTG
AACCTAAACGTGCTG-3’ (sense) and 5’-TCTT
CGCAAATCCTAATCCAAT-3’ (antisense). Amplifi-
cations were performed in a 25 @ reaction mixture
containing 0.3 @vl of each primer, 200 @vl of dNTPs,
buffer (50 mM KCl, 10 mM Tris-HCl, pH 8.3, 1 mM
MgC&), and 0.5 U of Thermus aquaticus DNA poly-
merase (AmpliTaq GoldTM, Perkin Elmer, Branchburg,
NJ, USA). The samples were incubated for 7 min at
95 “C for denaturation prior to cycles (94 “C X 45 s,
56 “C [dhfi 51 and 591 or 59 “C [dhps 4371 X 45 s, and
72 “C X 45 s). After 30 cycles, primer extension was
continued for 5 min at 72 “C. PCR products of pfcrt,
dhfr, and dhps genes were sequenced by use of an-ABI
PRISM@ Big: Dve Terminator Cvcle seauencinn Kit
(Perkin-Elm& detus@) following* the manufact~rer’s
protocol (P/N 4303149 Revision C, 1998). PCR pro-
ducts were purified by use of a QIAquick@ PCR Pur-
666
ification Kit (Qiagen@, Hilden, Germany). Fluorescent
PCR products were sequenced in an ABI PRISM@
3100.
Data entry and analysis
Data were entered on Epi-Info 6.04 software (CDC,
Atlanta, GA, USA) and individually checked for accu-
racy. Failure rates for each drug were expressed as the
number of failures (ETF and LTF) over the total num-
ber of patients followed-up according to protocol, with
associated 95% confidence intervals (95% CIs). Re-
infections detected by PCR analysis were reclassified as
ATR. Failure rates in the 2 treatment groups were
compared by Mantel-Haenszel x2 test.
Results
Response to chloroquine and SP treatment
In total, 311 children were referred to the study
between September and November 2000, out of whom
141 were included (Figure). Of the 170 exclusions, 65
(38%) had a history of previous antimalarial intake, 57
(34%) presented with concomitant acute respiratory
infection or otitis, 52 (3 1%) had a negative smear, and
47 (28%) had a parasite density below the inclusion
threshold. Children treated with chloroquine and SF
were similar in their baseline characteristics (Table 1).
Parasitaemia was generally low: only 27/141 children
(19%) had a density above 10 OOO/pL. The apparent
difference in gender ratio was not statistically signifi-
cant (P = 0.46).
Due to the alarming preliminary results, chloroquine
enrolment was ended early, and a total of 61 children
were assigned to this group. As can be seen from the
Figure, 50 children (82%) completed 14-d and 28-d
follow-up. Table 2 shows the therapeutic responses of
-v.,
141 included
1
/
r;..-l.
61 treated with CO
treatment
9 withdrawn
6 acute respiratmy
infection
1 meningitis
1 severe injury
1 mistakenly received
rescue medication
. 2 lost to follow-up
pg.
Figure. Study enrolment details for 311 children with clinically suspected malaria, Harper, Liberia, 2000.
F. CHECCHI ETAL.
the children to chloroquine at day 14 and day 28.
Overall, a mere 8/50 (16%) of children treated with
chloroquine completed 28 d of follow-up without ex-
periencing recurrent parasitaemia.
In the SP group, 80 children were included; 68
(85%) completed 14 d of follow-up, and 66 (83%)
completed 28 d (Figure). Only 20/66 (30%) of chil-
dren treated with SP responded to treatment and
remained parasite-free for the duration of follow-up
(Table 2). PCR analysis was performed on 15 out of
the 36 late failures in the SP group (42%) and 5
reinfections and 10 recrudescences were detected. As-
suming that the 21 failures not genotyped were recru-
descences, the PCR-adjusted day 28 failure rate for SP
thus becomes 41/66 (62.1%, 95% CI 49.3-73.8%).
Alternatively, we can apply the proportion of reinfec-
tions observed among the 15 LTF genotyped (5/15) to
the 21 LTF not genotyped, and extrapolate a more
realistic SP failure rate of 34/66 (51.5%, 95% CI
38.9-64.0%).
SP was significantly better than chloroquine in terms
of proportion of early failures (15% vs. 36%, P = 0.01)
and failure rate at day 14 (49% vs. 74%, P=O.O06).
No statistical difference in baseline characteristics was
observed between children who completed the study
and study withdrawals/losses to follow-up. A quality
control of malaria diagnosis, performed on 109 slides
(11% of total), yielded 93.3% agreement.
Results of genomic analysis
The pfcrt 76 codon was determined in pretreatment
isolates from 23 children. All isolates carried the K-
76T mutation, either alone (21 isolates) or mixed with
the wild-type allele (2 isolates). The K-76T mutation
was also found in 7 out of 7 post-chloroquine treatment
170 excluded /
f
1
I
allocation
/
/
t
80 treated withSl’
I
1
9 withdrawn
6 acute respiratory
infection
1 measles
1 unknown fever
1 mistakenly received
rescue medication
. 2 lost to follow-up
I
Pie
l l follow-up
I
PLASMODIUM FALCIPARUM DRUG RESISTANCE 667

Table 1. Baseline characteristics of 141 study children, Harper, Liberia, 2000

Treatment group

Characteristic Chloroquine (n = 61) SP (n = 80)

Mean (SD) age (months) 22.0 (13.9) 26.2 (15.6)
Gender ratio (M/F) 0.91 (29132) 0.70 (33/47)
Mean (SD) weight/height as % of median 98.1 (8.4) 97.8 (7.8)
Mean (SD) initial axillary temperature (“C) 37.9 (0.9) 37.9 (1.1)
Geometric mean (range) initial parasitaemia (/pL) 4016 (1000-90 000) 4111 (1000-23780)
SF’,sulfadoxine-pyrimethamine.

Table 2. Therapeutic response of study children to chloroquine and sulfadoxine-pyrimethamine at day

14 and day 28, unadjusted for polymerase chain reaction analysis, Harper, Liberia, 2000
Chloroquine Sulfadoxine-pyrimethamine

n (%I 95% CI n (%I 95% CI

Outcome at day 14
Early treatment failure 18 22.9-50.8 10 7.3-25.4
Late treatment failure 19 lZi 24.7-52.8 23 fEj 22.8-46.3
Failure 37 59.7-85.4 36.2-61.0
Adequate treatment response 13 g:g 14.6-40.3 2; g;j 39.0-63.8
Total 50 (1oo:o) 68 (1oo:o)
Outcome at day 28
Early treatment failure 18 22.9-50.8 10 i:z; 7.5-26.1
Late treatment failure 24 33.7-62.6 36 41.8-66.9
Failure 42 70.9-92.8 46 ~;;I:{ 57.1-80.4
Adequate treatment response 7.2- 29.1 20 19.6-42.9
Total 66 (100.0)
95% CI, 95% confidence interval.

failure isolates. DNA sequencing also showed a very
high frequency of a triple dhfr mutation at codons 108,
51, and 59 (S108N, N511, C59R): 21 out of 25
pretreatment isolates (84%) and all (17/17) post-SP
treatment isolates had triple dhfr mutants. Among the
14 tested pretreatment isolates, 11 (79%) possessed the
A437G mutation at gene dhps, either alone (6 isolates)
or mixed with the wild-type allele (5 isolates); 3 isolates
had the wild-type allele alone. Nine isolates carrying
the A437G mutation at gene dhps also had the triple
dhfr mutation.
Discussion
Results of this study in viva showed alarming levels
of parasitological resistance to both chloroquine and
SP in this area of Liberia. The true parasitological
failure rate for chloroquine may be somewhere between
74.0% (result at day 14) and 84.0% (result at day 28).
Given the intensity of transmission, many episodes of
recurrent parasitaemia occurring between day 14 and
day 28 are likely to have been reinfections. Even if we
only consider results up to day 14, our study suggests
that resistance to chloroquine has reached unacceptable
levels in Harper. Of particular concern among children
treated with this drug is the high proportion of early
recrudescences (36%).
Our results for chloroquine in viva are further corro-
borated by findings of the related genomic analysis.
The ubiquity of the pfcrt I<-76T mutation observed in
this relatively limited sample is comparable with that
reported in other African countries where chloroquine-
resistant parasites are predominant (WELLEMS &
PLOWE, 2001). The apparent discrepancy between fail-
ure rate in vivo (74% at day 14) and frequency of pfcrt
mutants (100%) is probably explained by the fact that
some children may have spontaneously cleared their
chloroquine-resistant infections through immune me-
chanisms.
High chloroquine resistance in Harper is consistent
with its extensive use both within and outside the
official health system to cure episodes of fever. Self-
medication and unregulated sale by private vendors
occur with frequency in Harper, mirroring the pattern
in similar African settings (FOSTER, 199 1). At the same
time, local clinicians’ perception before the study ap-
peared to be that chloroquine was still efficacious: this
may have been due in part to the early antipyretic effect
this drug provides even in subjects infected with a
resistant strain (BOJANG et al., 1998).
A disappointing efficacy was also observed for SP in
this study. Though the proportion of early failures with
SP (15%) was significantly lower than with chloro-
quine, by day 14 48.5% of children had already experi-
enced a recrudescence. Unfortunately, our day 28
results are based on partial genotyping of late failures to
identify reinfections: based on these data, the true
parasitological failure rate of SP is best estimated at
51.5%.
As with chloroquine, genomic data confirm the re-
sults in viva for SF. A very high prevalence of the triple
dhfr mutation and of the dhps A437G mutation were
observed in our sample. The relative role of dhfr vs.
dhps mutations in SP resistance is still controversial.
According to some authors, the presence of the triple
dhfi mutation alone could be used to predict the clinical
outcome of SP treatment (NZILA et al., 2000) and the
single dhfr codon 59 may suffice as a molecular marker
of SP failure (KUBLIN et al., 2002). In other studies,
the triple dhfr mutation was not always associated with
SP therapeutic failure (BASCO et al., 2000) and thus
both dhfi and dhps genotypes in l? falciparum popula-
tions should be used to predict the efficacy of SP.
There is also a controversy about which codons to
consider in dhps (DIOURTE et al., 1999). In Africa, the
dhps A437G and K540E mutations were most strongly
associated with SP failure (NZILA et al., 2000).
Resistance to SP in Harper is harder to account for,
though high SP failure rates have been reported even

from areas where the drug is not used as first-line
therapy (MUTABINGWA et al., 2001). The rapid selec-
tion of dhfr point mutations at codons 108, 51, and 59
under antifolate pressure has also been described
(DOUMBO et al., 2000). In any case, these findings once
again show the ease with which mutations encoding
resistance to SP arise and support the hypothesis that
SP monotherapy will have a limited lifespan in Africa.
Our estimates of resistance in viva rely on a parasito-
logical definition of recrudescence and might have been
lower had we used the WHO (1996) definitions of LTF
(parasitaemia if accompanied by fever). Nevertheless,
evidence shows that most children who remain para-
sitaemic after antimalarial therapy eventually develop
symptoms (thereby fulfilling the clinical criteria of fail-
ure); however, this often occurs beyond the follow-up
period, thus leading to misclassification of failures as
adequate responders (BLOLAND et al., 1993; MUTA-
BINGWA et al., 2001). In any case, we consider that
absence of symptoms (fever) should not lead to classifi-
cation of parasitological recrudescences as adequate
responses. In addition, when the study population con-
sists of children and there is a strong suspicion of high
resistance to the study drug, failure to administer im-
mediate rescue medication to asymptomatic failures
carries considerable risks for the patient, notably sud-
den aggravation and further decline in haemoglobin
levels, with consequent risk of severe anaemia if para-
sitaemia persists (SLUTSI(ERet al., 1994).
In Harper, low chloroquine and SP efficacy is likely
to lead to increased malaria-related morbidity and
mortality, as demonstrated in other settings (TRAPE,
2001). The effect might be particularly dire in this poor
community, where resources to prevent infective ano-
pheline mosquito bites are limited and, apart from
quinine, no other therapies are available. Our results
thus underline the urgent need to deploy more effica-
cious antimalarials as Replacement for boih chloroquine
and SP in Haroer. Combinations based on artemisinin
derivatives off& the fastest reduction in parasitaemia,
lead to greatly improved cure rates and may reduce
commur&y tr&sm&sion of the disease becausk of their
sametocidal effect (‘WHITE & OLLIARO, 1996). The
artemisinin componknt, however, must be associated
with a sufficiently efficacious partner drug. Amodia-
quine seemed like a possible candidate for an artesu-
nate combination therapy in Harper, and a study of its
efficacy has been conducted (CHECCHI et al., 2002).
Elsewhere in Liberia, chloroquine remains the main-
stay of antimalarial treatment, with SP as second-line
therapy. While care should be taken to extrapolate
these results to other sites in the country, our study
does show that chloroquine-resistant l? falciparum
strains may be highly prevalent throughout this region.
It also provides hitherto missing information on resis-
tance to SF in Liberia. We strongly recommend that
surveillance of antimalarial resistance in Liberia and
neighbouring regions be intensified and include both
chloroquine and SP at multiple sentinel sites.
Acknowledgements
We thank the children and families who consented to
participate in this study. We are grateful for the excellent work
of our study team members (data collector Andrew Colley,
laboratory technician Alfred Nyuma, nurse aide Agatha Satia,
home visitors Robert Kun and John Weah, counsellor Nanu
Yancy) and for the support of clinicians and authorities of JJ
Dossen Hospital and Sacred Heart Clinic. Many thanks to
Katleen Willems and Katherine Johnson, for the quality con-
trol of malaria slides, and to Sayeh Jafari for sequencing of
parasite DNA. Thanks also to Dounia Bitar, Marc Gastellu,
Graziella Godain and Brigitte Vasset (MSF headquarters,
Paris), for support and advice during the study, and to Domin-
ique Legros (Epicentre) for advice and technical review of the
manuscript.
F. CHECCHIETAL.
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I I
1 Book Review 1 years to have any significant impact on heath care, and
I I
Genomics and World Health. Report of the Advi-
sory Committee on Health Research. Geneva: World
Health Organization, 2002. x + 248~~. Price Sw.fr.35/
US$31.50 (in developing countries Sw.fr.14). ISBN
92-4-154554-2.
The recent publication of the genome sequences of
both Plasmodiunz falciparum and Anopheles gambiae has
served to focus the debate on the impact of genomics
on tropical diseases. It is often stated that there is a
clear need to balance the enthusiasm for this cutting-
edge scientific research with conventional public health
measures. It is therefore timely that this publication on
Genomics and World Health by the WHO Advisory
Committee on Health Research is available. This book
sets out many of the arguments in favour of genomics
and its potential application, yet also tempers this with
the related ethical, social and economic issues that need
to be addressed.
The book begins with an introduction to basic genet-
ics, molecular genetics and technologies such as micro-
arrays and proteomics. The presentation style of this
section is easy to read, and should prove an invaluable
introduction for the non-specialist. A section on the
influence of genomics on heath care follows where the
issues explored include vaccine and drug development,
communicable diseases, cancers, and multifactorial
disease.
A key section deals with the ‘Relevance and Time-
scale of Advances in Genomics to Global Health’. It is
often argued that the field of genomics will take many
669
sible for sulfone and sulfonamide resistance in Plasmodium
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., _I
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malaria. Journal of Infectious Diseases, 184, 770-776.
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of antimalarial drug resistance: rationale for combination
chemotherapy for malaria. Parasitology Today, 12, 399-401.
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Marsh, I<., Snow, R. W., Kokwaro, G., Ouma, J., Hien, T.
T., Molyneux, M. E., Taylor, T. E., Newbold, C. I., Rue-
bush, T. K., Danis, M., Greenwood, B. M., Anderson, R.
M. & Olliaro, I’. (1999). Averting a malaria disaster. Lancet,
353.196551967.
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drugs for uncomplicated falciparmm malaria in areas with intense
transmission. Geneva: World Health Organization, WHO/
MAL’96.1077.
Received 21 March 2002; revised 12 June 2002; accepted
for publication 18June 2002
the authors underline the unpredictable nature of this
research. However, a case is also made, and repeated in
a later section, of the need for advocates of public
health to ensure that the balance is maintained between
epidemiology and clinical science on the one hand, and
basic research on the other. This line of reasoning is
continued in the section that deals with the potential of
genomics for the health of developing countries. Perti-
nent examples such as the inherited disorders of hae-
moglobin and drug resistance in pathogens serve to
highlight the quick-wins where genomics could have
a relatively immediate impact. Long-term goals are
shown by the steps being taken in Brazil, India, and
China to set up centres of genomic research that could
serve as models for others. However the fear remains
that genomics will only aid to accelerate the gap be-
tween health care in developed and developing coun-
tries. The section on Justice and Resource allocation
deals head-on with these aspects, and outlines many of
the key problems facing developing countries in terms
of research, intellectual property rights and database
ownership.
At all stages the book is well written, using examples
and anecdotes to explain many of the complex issues
involved with this field of research. A must read for
anyone interested in this field.
Stephen Gordon
Veterinary Laboratories Agency
Woodham Lane
New Haw
Surrey KTl.5 3NB, UK