title: Increased pfmdr1 gene copy number and the decline in pfcrt and pfmdr1 resistance alleles in Ghanaian Plasmodium falciparum isolates after the change of anti-malarial drug treatment policy.
abstract: BACKGROUND
  With the introduction of artemisinin-based combination therapy (ACT) in 2005, monitoring of anti-malarial drug efficacy, which includes the use of molecular tools to detect known genetic markers of parasite resistance, is important for first-hand information on the changes in parasite susceptibility to drugs in Ghana. This study investigated the Plasmodium falciparum multidrug resistance gene (pfmdr1) copy number, mutations and the chloroquine resistance transporter gene (pfcrt) mutations in Ghanaian isolates collected in seven years to detect the trends in prevalence of mutations.
  
  
  METHODS
  Archived filter paper blood blots collected from children aged below five years with uncomplicated malaria in 2003-2010 at sentinel sites were used. Using quantitative real-time polymerase chain reaction (qRT-PCR), 756 samples were assessed for pfmdr1 gene copy number. PCR and restriction fragment length polymorphism (RFLP) were used to detect alleles of pfmdr1 86 in 1,102 samples, pfmdr1 184, 1034, 1042 and 1246 in 832 samples and pfcrt 76 in 1,063 samples. Merozoite surface protein 2 (msp2) genotyping was done to select monoclonal infections for copy number analysis.
  
  
  RESULTS
  The percentage of isolates with increased pfmdr1 copy number were 4, 27, 9, and 18% for 2003-04, 2005-06, 2007-08 and 2010, respectively. Significant increasing trends for prevalence of pfmdr1 N86 (×(2) = 96.31, p <0.001) and pfcrt K76 (×(2) = 64.50, p <0.001) and decreasing trends in pfmdr1 Y86 (x(2) = 38.52, p <0.001) and pfcrt T76 (x(2) = 43.49, p <0.001) were observed from 2003-2010. The pfmdr1 F184 and Y184 prevalence showed an increasing and decreasing trends respectively but were not significant (×(2) = 7.39,p=0.060; ×(2) = 7.49, p = 0.057 respectively). The pfmdr1 N86-F184-D1246 haplotype, which is alleged to be selected by artemether-lumefantrine showed a significant increasing trend (×(2) = 20.75, p < 0.001).
  
  
  CONCLUSIONS
  Increased pfmdr1 gene copy number was observed in the isolates analysed and this finding has implications for the use of ACT in the country although no resistance has been reported. The decreasing trend in the prevalence of chloroquine resistance markers after change of treatment policy presents the possibility for future introduction of chloroquine as prophylaxis for malaria risk groups such as children and pregnant women in Ghana.
authors.affiliation: Epidemiology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, PO Box LG581, Legon, Ghana. nduah@noguchi.ug.edu.gh.
authors.forename: Nancy O
authors.initials: NO
authors.lastname: Duah
authors.forename: Sena A
authors.initials: SA
authors.lastname: Matrevi
authors.forename: Dziedzom K
authors.initials: DK
authors.lastname: de Souza
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Binnah
authors.forename: Mary M
authors.initials: MM
authors.lastname: Tamakloe
authors.forename: Vera S
authors.initials: VS
authors.lastname: Opoku
authors.forename: Christiana O
authors.initials: CO
authors.lastname: Onwona
authors.forename: Charles A
authors.initials: CA
authors.lastname: Narh
authors.forename: Neils B
authors.initials: NB
authors.lastname: Quashie
authors.forename: Benjamin
authors.initials: B
authors.lastname: Abuaku
authors.forename: Christopher
authors.initials: C
authors.lastname: Duplessis
authors.forename: Karl C
authors.initials: KC
authors.lastname: Kronmann
authors.forename: Kwadwo A
authors.initials: KA
authors.lastname: Koram
mesh_terms: D000962:Antimalarials / Q000494:pharmacology* / Q000627:therapeutic use; D002675:Child, Preschool; D016054:DNA, Protozoan / Q000235:genetics; D004351:Drug Resistance; D005260:Female; D018628:Gene Dosage; D005787:Gene Frequency; D005869:Ghana / Q000453:epidemiology; D006291:Health Policy; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000453:epidemiology / Q000469:parasitology*; D008297:Male; D026901:Membrane Transport Proteins / Q000235:genetics*; D027425:ATP-Binding Cassette, Sub-Family C Proteins / Q000235:genetics*; D020125:Mutation, Missense; D010963:Plasmodium falciparum / Q000145:classification / Q000187:drug effects / Q000235:genetics* / Q000302:isolation & purification; D012150:Polymorphism, Restriction Fragment Length; D015800:Protozoan Proteins / Q000235:genetics*; D060888:Real-Time Polymerase Chain Reaction
chemical_list: D000962:Antimalarials; D016054:DNA, Protozoan; D026901:Membrane Transport Proteins; D027425:ATP-Binding Cassette, Sub-Family C Proteins; D015800:Protozoan Proteins; C513498:Mdr1 protein, Plasmodium falciparum; C416369:PfCRT protein, Plasmodium falciparum