The current spread of multidrug-resistant malaria in south-east Asia is likely to be the result of two mutations combining in 2008…

Malaria parasite spread rapidly

The retrospective genetic study – published in The Lancet Infectious Diseases journal on 1 February 2018 – shows how the multidrug-resistant parasite, Plasmodium falciparum, gained increased biological fitness, spreading rapidly through the region unnoticed for five years until the outbreak became apparent in 2013. The authors warn that malaria programmes should closely monitor genetic mutations to mitigate the possibility of the parasite becoming untreatable.

Combination of drugs

Typically, treatment for malaria involves a combination of drugs including artemisinin – a potent and fast-acting antimalarial drug – and a longer-acting partner drug to ensure that all parasites are killed and to prevent the emergence of resistance.

In 2008, Plasmodium falciparum started to become resistant to artemisinin in western Cambodia. Since then, resistance has been observed in other parts of Cambodia, Thailand, Vietnam, Myanmar, and Laos.

From 2013, the frequency of complete treatment failure in patients receiving a drug combination of dihydroartemisinin and piperaquine increased rapidly in Cambodia, northeast Thailand, and Vietnam.

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A dilemma

“Malaria policy makers now face a dilemma. On one hand, malaria remains treatable and its prevalence has been reduced to low enough levels to aim to eliminate the disease in Cambodia and neighbouring countries. However, the situation is fragile, and it is unclear how the parasite population will evolve in response to new interventions,” says Roberto Amato, Wellcome Sanger Institute, UK.

Embracing new technologies essential

“While it would be catastrophic if resistance developed in the same way for the last remaining anti-malarial drugs, it is now possible to conduct genetic surveillance of malaria cases, allowing researchers to respond as soon as possible to changes in the parasite population. It is important that we embrace these technologies so that major outbreaks of resistance do not go unnoticed in the future, and to reduce the risk of a global health emergency,” concludes Amato.

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