Evaluación de la eficacia de los medicamentos antimaláricos en Tarapacá, Amazonas colombiano

Introduction. The current antimalarial drug policy in Colombia has been based on studies conducted in Antioquia and the Pacific Coast. However, the efficacy of antimalarial drugs in other endemic regions is unknown.Objective. The therapeutic efficacy of three monotherapies was assessed: amodiaquine and sulfadoxine/pyrimethamine for uncomplicated Plasmodium falciparum malaria, and chloroquine for Plasmodium vivax malaria in the municipality of Tarapacá, located in the Colombian province of Amazonas.Materials and methods. Treatment was supervised and clinical/parasitological follow-up was undertaken through a 28-day period following to World Health Organization standard protocols for subjects with a single P. falciparum or P. vivax infection.Results. Due to a decrease in malaria transmission at the time of the study, the sample size was very small. The treatment failed for two subjects who received amodiaquine, and treatment with sulfadoxine/pyrimethamine was discontinued due to a high frequency of therapeutic failures (7/8). Most subjects (18/20) with P. vivax infections showed an adequate therapeutic response.Conclusions. The use of sulfadoxine/pyrimethamine in Tarapacá, and possibly in the Amazon region of Colombia, needs to be reviewed. Therapeutic efficacy studies in other endemic areas in the Amazon and Orinoco regions in Colombia are desirable but not feasible. Alternative methods such as in vitro assays or detection of molecular markers for resistance in the parasite can provide a basis for decisions concerning antimalarial drug policy for the Amazon and Orinoco regions in Colombia.Introducción. La selección de los esquemas de tratamiento para malaria en Colombia se ha basado principalmente en estudios realizados en Antioquia y en la costa Pacífica, pero se desconoce la eficacia de los antimaláricos en la Orinoquia y Amazonia colombianas.Objetivo. Evaluar la eficacia terapéutica de tres monoterapias: amodiaquina y sulfadoxina/pirimetamina para el tratamiento de malaria no complicada por Plasmodium falciparum y de cloroquina para el tratamiento de malaria por Plasmodium vivax en Tarapacá, departamento del Amazonas.Materiales y métodos. Suministro de tratamiento supervisado y seguimiento clínico y parasitológico durante 28 días según protocolos estandarizados de sujetos con infección única por P. falciparum o P. vivax.Resultados. No fue posible completar el tamaño de muestra por disminución marcada en la transmisión. En el grupo de P. falciparum, el tratamiento con amodiaquina fracasó en dos sujetos; se suspendió el grupo de sulfadoxina/pirimetamina por alto número de fracasos terapéuticos (7/8). En el grupo de P. vivax, la mayoría (18/20) presentó respuesta adecuada al tratamiento.Conclusiones. Es necesario reconsiderar el uso de sulfadoxina/pirimetamina en Tarapacá y posiblemente en el Amazonas colombiano. Se requieren estudios de eficacia terapéutica en otras áreas endémicas, o la utilización de métodos in vitro o moleculares, para definir el esquema de tratamiento para malaria por P. falciparum en la Orinoquia y Amazonia colombianas

An assessment of false positive rates for malaria rapid diagnostic tests caused by non-Plasmodium infectious agents and immunological factors.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) can produce false positive (FP) results in patients with human African trypanosomiasis and rheumatoid factor (RF), but specificity against other infectious agents and immunological factors is largely unknown. Low diagnostic specificity caused by cross-reactivity may lead to over-estimates of the number of malaria cases and over-use of antimalarial drugs, at the cost of not diagnosing and treating the true underlying condition. METHODS: Data from the WHO Malaria RDT Product Testing Programme was analysed to assess FP rates of 221 RDTs against four infectious agents (Chagas, dengue, Leishmaniasis and Schistosomiasis) and four immunological factors (anti-nuclear antibody, human anti-mouse antibody (HAMA), RF and rapid plasma regain). Only RDTs with a FP rate against clean negative samples less than 10% were included. Paired t-tests were used to compare product-specific FP rates on clean negative samples and samples containing non-Plasmodium infectious agents and immunological factors. RESULTS: Forty (18%) RDTs showed no FP results against any tested infectious agent or immunological factor. In the remaining RDTs significant and clinically relevant increases in FP rates were observed for samples containing HAMA and RF (P<0.001). There were significant correlations between product-matched FP rates for RF and HAMA on all RDT test bands (P<0.001), and FP rates for each infectious agent and immunological factor were also correlated between test bands of combination RDTs (P≤0.002). CONCLUSIONS: False positive results against non-Plasmodium infectious agents and immunological factors does not appear to be a universal property of malaria RDTs. However, since many malaria RDTs have elevated FP rates against HAMA and RF positive samples practitioners may need to consider the possibility of false positive results for malaria in patients with conditions that stimulate HAMA or RF

Clinical evaluation of a loop-mediated amplification kit for diagnosis of imported malaria.

BACKGROUND: Diagnosis of malaria relies on parasite detection by microscopy or antigen detection; both fail to detect low-density infections. New tests providing rapid, sensitive diagnosis with minimal need for training would enhance both malaria diagnosis and malaria control activities. We determined the diagnostic accuracy of a new loop-mediated amplification (LAMP) kit in febrile returned travelers. METHODS: The kit was evaluated in sequential blood samples from returned travelers sent for pathogen testing to a specialist parasitology laboratory. Microscopy was performed, and then malaria LAMP was performed using Plasmodium genus and Plasmodium falciparum-specific tests in parallel. Nested polymerase chain reaction (PCR) was performed on all samples as the reference standard. Primary outcome measures for diagnostic accuracy were sensitivity and specificity of LAMP results, compared with those of nested PCR. RESULTS: A total of 705 samples were tested in the primary analysis. Sensitivity and specificity were 98.4% and 98.1%, respectively, for the LAMP P. falciparum primers and 97.0% and 99.2%, respectively, for the Plasmodium genus primers. Post hoc repeat PCR analysis of all 15 tests with discrepant results resolved 4 results in favor of LAMP, suggesting that the primary analysis had underestimated diagnostic accuracy. CONCLUSIONS: Malaria LAMP had a diagnostic accuracy similar to that of nested PCR, with a greatly reduced time to result, and was superior to expert microscopy

Prototype Positive Control Wells for Malaria Rapid Diagnostic Tests: Prospective Evaluation of Implementation Among Health Workers in Lao People's Democratic Republic and Uganda.

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7-1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management

Defining the next generation of Plasmodium vivax diagnostic tests for control and elimination: Target product profiles.

The global prevalence of malaria has decreased over the past fifteen years, but similar gains have not been realized against Plasmodium vivax because this species is less responsive to conventional malaria control interventions aimed principally at P. falciparum. Approximately half of all malaria cases outside of Africa are caused by P. vivax. This species places dormant forms in human liver that cause repeated clinical attacks without involving another mosquito bite. The diagnosis of acute patent P. vivax malaria relies primarily on light microscopy. Specific rapid diagnostic tests exist but typically perform relatively poorly compared to those for P. falciparum. Better diagnostic tests are needed for P. vivax. To guide their development, FIND, in collaboration with P. vivax experts, identified the specific diagnostic needs associated with this species and defined a series of three distinct target product profiles, each aimed at a particular diagnostic application: (i) point-of-care of acutely ill patients for clinical care purposes; (ii) point-of-care asymptomatic and otherwise sub-patent residents for public health purposes, e.g., mass screen and treat campaigns; and (iii) ultra-sensitive not point-of-care diagnosis for epidemiological research/surveillance purposes. This report presents and discusses the rationale for these P. vivax-specific diagnostic target product profiles. These contribute to the rational development of fit-for-purpose diagnostic tests suitable for the clinical management, control and elimination of P. vivax malaria

Towards harmonization of microscopy methods for malaria clinical research studies

Microscopy performed on stained films of peripheral blood for detection, identification and quantification of malaria parasites is an essential reference standard for clinical trials of drugs, vaccines and diagnostic tests for malaria. The value of data from such research is greatly enhanced if this reference standard is consistent across time and geography. Adherence to common standards and practices is a prerequisite to achieve this. The rationale for proposed research standards and procedures for the preparation, staining and microscopic examination of blood films for malaria parasites is presented here with the aim of improving the consistency and reliability of malaria microscopy performed in such studies. These standards constitute the core of a quality management system for clinical research studies employing microscopy as a reference standard. They can be used as the basis for the design of training and proficiency testing programmes as well as for procedures and quality assurance of malaria microscopy in clinical research.Publisher PDFPeer reviewe

Diagnostic accuracy of a LAMP kit for diagnosis of imported malaria in Switzerland

The diagnosis of acute malaria in non-endemic countries is still carried out largely by microscopic examination of thick and thin smears or rapid diagnostic tests. Low-density infections might be missed, however, but the more sensitive PCR is more expensive, complex and requires considerable more time.; We examined the suitability of a new loop-mediated isothermal DNA-amplification kit (LAMP) for malaria diagnosis in febrile returning travellers in comparison to qPCR and microscopic examination in a prospective study in a non-endemic setting at the Swiss TPH.; Among 205 complete datasets, 43 samples were positive for malaria by microscopy, with Plasmodium falciparum (35 cases) being the most frequent species. All these samples were positive by both LAMP and qPCR, too. An additional 4 samples negative by microscopy were positive by both LAMP and qPCR. Three of these samples were follow-up samples taken after start of treatment in patients originally identified as positive by microscopy.; The LAMP performed exactly as did the qPCR and is a very valuable diagnostic alternative with a potential of being used also in endemic settings