title: Therapeutic efficacy and artemisinin resistance in northern Myanmar: evidence from in vivo and molecular marker studies.
abstract: In Myanmar, three types of artemisinin-based combination therapy (ACT) are recommended as first-line treatment of uncomplicated falciparum malaria: artemether-lumefantrine (AL), artesunate-mefloquine (AS + MQ), and dihydroartemisinin-piperaquine (DP). Resistance to both artemisinins and ACT partner drugs has been reported from the Greater Mekong Sub-region, and regular efficacy monitoring of the recommended ACT is conducted in Myanmar. This paper reports on results from studies to monitor the efficacy of the three forms of ACT in sentinel sites in northern Myanmar, and investigations of mutations in the Kelch13 (k13) propeller domain.
  
  
  
  Seven therapeutic efficacy studies were conducted in 2011-12 and 2014 in three sentinel sites in Myanmar (Tamu, Muse, Tabeikkyin). Three studies were done for the evaluation of AL (204 patients), two studies for AS + MQ (119 patients) and two studies for DP (147 patients). These studies were done according to 2009 standard WHO protocol. Polymorphisms in the k13 propeller domain were examined in dried blood spots collected on day 0. The primary endpoint was adequate clinical and parasitological response (ACPR) on day 28 for AL and on day 42 for DP and AS + MQ, corrected to exclude re-infection using polymerase chain reaction (PCR) genotyping. Safety data were collected through self-reporting.
  
  
  
  PCR-corrected ACPR was 97.2-100% for AL, 98.6-100% for AS + MQ and 100% for DP across the study sites and years. All studies found a prevalence of k13 mutations (>440) above 23% in the day-0 samples. The F446I mutation was the most common mutation, making up 66.0% of the mutations found. Seven out of nine day-3 positive patients were infected with k13 wild type parasites. The remaining two cases with day-3 parasitaemia had the P574L mutation.
  
  
  
  The efficacy of AL, AS + MQ and DP remains high in northern Myanmar despite widespread evidence of k13 mutations associated with delayed parasite clearance. This study showed that already in 2012 there was a high frequency of k13 mutations in Myanmar on the border with India. The high efficacy of the recommended ACT gives confidence in the continued recommendation of the use of these treatments in Myanmar. Trial registration numbers ACTRN12611001245987 (registered 06-12-2011) and ACTRN12614000216617 (registered 28-02-2014).
authors.affiliation: Department of Medical Research (Pyin Oo Lwin Branch), Ministry of Health and Sports, Pyin Oo Lwin, 05062, Myanmar.
authors.forename: Moe Kyaw
authors.initials: MK
authors.lastname: Myint
authors.affiliation: World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Rasmussen
authors.affiliation: National Malaria Control Programme, Ministry of Health and Sports, Nay Pyi Taw, Myanmar.
authors.forename: Aung
authors.initials: A
authors.lastname: Thi
authors.affiliation: World Health Organization, Bangkok, Thailand.
authors.forename: Dorina
authors.initials: D
authors.lastname: Bustos
authors.affiliation: World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland.
authors.forename: Pascal
authors.initials: P
authors.lastname: Ringwald
authors.affiliation: Department of Medical Research (Pyin Oo Lwin Branch), Ministry of Health and Sports, Pyin Oo Lwin, 05062, Myanmar. dr.khinlin.dir@gmail.com.
authors.forename: Khin
authors.initials: K
authors.lastname: Lin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000962:Antimalarials / Q000494:pharmacology* / Q000627:therapeutic use*; D037621:Artemisinins / Q000494:pharmacology* / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D016054:DNA, Protozoan / Q000737:chemistry / Q000235:genetics; D004351:Drug Resistance; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D017125:Genes, Protozoan; D006801:Humans; D008288:Malaria / Q000188:drug therapy* / Q000469:parasitology; D008297:Male; D008875:Middle Aged; D002052:Myanmar; D010961:Plasmodium / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D011110:Polymorphism, Genetic; D011446:Prospective Studies; D017422:Sequence Analysis, DNA; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D016054:DNA, Protozoan; C031327:artemisinin
keywords: Molecular markers; Myanmar; Plasmodium falciparum; Treatment efficacy; k13