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Background  Artesunate/sulphadoxine-pyrimethamine (AS/SP) has been the first-line treatment for falciparum malaria in Sudan since 2004. The impact of this combination on anti-malarial resistance-associated molecular markers has not been investigated. In this study, an evaluation of the efficacy and prevalence of drug resistance alleles ( pfcrt ,  pfmdr1 ,  pfdhfr  and  pfdhps ) eight years after the adoption of AS/SP in eastern Sudan is reported.    Methods  A 28-day follow-up efficacy trial of AS/SP was conducted in eastern Sudan during the 2012 transmission season. Blood smears were collected from patients on days 0, 1, 2, 3, 7, 14, 21 and 28. Blood spots on filter paper were obtained pre-treatment and on the day the patient was parasite positive by microscopy. Genotyping of alleles was performed by qPCR ( pfcrt 72 – 76  and  pfmdr1  copy number) and direct sequencing of  pfmdr1 ,  pfdhfr  and  pfdhps .    Results  Sixty-three patients out of 68 (93%) completed the 28-day follow-up, adequate clinical, and parasitological response occurred in 90.5% and 85.3% of the patients in the per-protocol and intent-to-treat analyses, respectively. PCR corrected per-protocol efficacy was 93.7%. The enrolment prevalence of  pfcrt -CVMNK was 30.2% and  pfmdr1 -N86 was 40.3%. The  pfmdr1  haplotype NFD occurred in 32.8% of pre-treatment samples and was significantly higher than previous reports (Fisher’s exact  p  = 0.0001). The  pfdhfr -51I/108N combination occurred in all sequenced isolates and 59R was observed in a single individual.  pfdhps  substitutions 436A, 437G, 540E, 581G and 613S were observed at 7.8, 77.3, 76.9%, 33.8% and 0.0%, respectively. Treatment failures were associated with the  pfdhps  haplotype SGEGA at these five codons (OR 7.3; 95% CI 0.65 - 368;  p  = 0.048).    Conclusion  The decrease of CQR associated genotypes reflects the formal policy of complete removal of CQ in Sudan. However, the frequency of markers associated with SP failure is increasing in this study area and may be contributing to the treatment efficacy falling below 90%. Further monitoring of AS/SP efficacy and of post-treatment selection of  pfdhfr  and  pfdhps  alleles  in vivo  is required to inform future treatment guidelines.

malaria journal

Selection of pfdhfr/pfdhps alleles and declining artesunate/sulphadoxine-pyrimethamine efficacy against Plasmodium falciparum eight years after deployment in eastern Sudan