Shifts in antimalarial drug policy since 2006 have rapidly selected P. falciparum resistance alleles in Angola

Abstract

BACKGROUNDPlasmodium falciparum resistance to chloroquine (CQ), the most widely used antimalarial drug, has historically posed a major threat to malaria control in Angola and throughout the world. Although Angola replaced CQ with artemisinin combination therapy (ACT) as a frontline treatment in 2006, malaria cases and deaths have recently been rising. CQ-resistance mutations may still be a contributing factor, given that (1) some also modulate resistance to ACT partner drugs and (2) ACT is not yet consistently implemented across Angola. It is important to continue monitoring all known resistance alleles in P. falciparum, but no studies have done so in Angola since 2012. METHODSWe sampled P. falciparum DNA from the blood of 50 hospital patients in Cabinda, Angola in 2018. Each infection was genotyped for 13 alleles in the genes crt, mdr1, dhps, dhfr, and kelch13, which collectively confer resistance to six common drugs. To analyze frequency trajectories over time, we also collated P. falciparum genotype data published from across Angola in the last two decades. RESULTSThe two most important alleles for CQ resistance, crt 72-76CVIET and mdr1 86Y, have both declined in frequency from respective highs of 98% in 1999 and 73% in 2003. However, the former remains at 71% frequency in this sample while the latter has dropped to just 7%. Of seven possible alleles for sulfadoxine-pyrimethamine (SP) resistance in dhps and dhfr, the average total number per isolate increased from 2.9 in 2004 to 4.4 in 2018. Finally, we detected no non-synonymous polymorphisms in kelch13, which is involved in artemisinin resistance in Southeast Asia. CONCLUSIONSChanges in drug policy in Angola since 2006 appear to have exerted strong selection on P. falciparum drug resistance alleles. Resistance to CQ is declining, but due to functional tradeoffs and novel selection at mdr1 loci, resistance to ACT partner drugs appears to be rising. More haplotype-based studies at mdr1 will be needed to understand the changing efficacy of multiple drugs. Finally, SP resistance has jumped rapidly since 2014, consistent with widespread use of intermittent SP treatment during pregnancy. These data can be used to support effective drug policy decisions in Angola.