title: Epidemic of Plasmodium falciparum malaria involving substandard antimalarial drugs, Pakistan, 2003.
abstract: Because of instability in eastern Afghanistan, new refugees crossed into the federally administered tribal areas of northwestern Pakistan in 2002. In 2003, we investigated an epidemic of Plasmodium falciparum malaria in 1 of the camps. Incidence was 100.4 cases/1,000 person-years; in other nearby camps it was only 2.1/1,000 person-years. Anopheline mosquitoes were found despite an earlier spray campaign. Documented clinical failures at the basic health unit prompted a drug resistance survey of locally manufactured sulfadoxine-pyrimethamine used for routine treatment. The in vivo failure rate was 28.5%. PCR analysis of the P. falciparum dihydrofolate reductase and dihyropteroate synthase genes showed no mutations associated with clinical failure. However, chemical analysis of the drug showed that it was substandard. As global incidence decreases and epidemics become more of a threat, enhanced quality assurance of control interventions is essential.
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. toby.leslie@lshtm.ac.uk
authors.forename: Toby
authors.initials: T
authors.lastname: Leslie
authors.forename: Harpakash
authors.initials: H
authors.lastname: Kaur
authors.forename: Nasir
authors.initials: N
authors.lastname: Mohammed
authors.forename: Kate
authors.initials: K
authors.lastname: Kolaczinski
authors.forename: Rosalynn L
authors.initials: RL
authors.lastname: Ord
authors.forename: Mark
authors.initials: M
authors.lastname: Rowland
mesh_terms: D000293:Adolescent; D000328:Adult; D000346:Afghanistan / Q000208:ethnology; D000818:Animals; D000852:Anopheles / Q000469:parasitology; D000962:Antimalarials / Q000009:adverse effects / Q000032:analysis / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D004338:Drug Combinations; D004351:Drug Resistance / Q000235:genetics; D005260:Female; D017125:Genes, Protozoan; D006801:Humans; D007223:Infant; D007300:Insect Control; D007303:Insect Vectors / Q000469:parasitology; D016778:Malaria, Falciparum / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission; D008297:Male; D010154:Pakistan / Q000453:epidemiology; D010963:Plasmodium falciparum / Q000187:drug effects / Q000235:genetics; D011159:Population Surveillance; D011739:Pyrimethamine / Q000009:adverse effects / Q000032:analysis / Q000592:standards; D012036:Refugees; D013413:Sulfadoxine / Q000009:adverse effects / Q000032:analysis / Q000592:standards; D055815:Young Adult
chemical_list: D000962:Antimalarials; D004338:Drug Combinations; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine