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Background  In late 2002, the health authorities of Mozambique implemented sulphadoxine-pyrimethamine (SP)/amodiaquine (AQ) as first-line treatment against uncomplicated falciparum malaria. In 2004, this has been altered to SP/artesunate in line with WHO recommendations of using Artemisinin Combination Therapies (ACTs), despite the fact that all the neighbouring countries have abandoned SP-drug combinations due to high levels of SP drug resistance. In the study area, one year prior to the change to SP/AQ, SP alone was used to treat uncomplicated malaria cases. The study described here investigated the immediate impact of the change to SP on the frequency of SP and CQ resistance-related haplotypes in the  Plasmodium falciparum  genes  Pfdhfr, Pfdhps  and  Pfcrt  before and a year after the introduction of SP.    Methods  Samples were collected during two cross sectional surveys in early 2002 and 2003 involving 796 and 692 children one year or older and adults randomly selected living in Maciana, an area located in Manhiça district, Southern Mozambique. Out of these, 171 and 173  P. falciparum  positive samples were randomly selected to measure the frequency of resistance- related haplotypes in  Pfdhfr, Pfdhps  and  Pfcrt  based on results obtained by nested PCR followed by sequence-specific oligonucleotide probe (SSOP)-ELISA.    Results  The frequency of the SP-resistance associated  Pfdhps  double mutant (SGEAA) haplotype increased significantly from 14% to 35% (P < 0.001), while the triple mutant  Pfdhfr  haplotype (CIRNI) remained high and only changed marginally from 46% to 53% (P = 0.405) after one year with SP as first-line treatment in the study area. Conversely, the combined  Pfdhfr/Pfdhps  quintuple mutant haplotype increased from 8% to 26% (P = 0.005). The frequency of the chloroquine resistance associated  Pfcrt -CVIET haplotype was above 90% in both years.    Conclusion  These retrospective findings add to the general concern on the lifespan of the combination of SP/artesunate in Mozambique. The high frequency of quintuple  Pfdhfr / Pfdhps  haplotypes found here as early as 2002 most likely cause ideal conditions for the development of artesunate tolerance in the  P. falciparum  populations and may even endanger the sensitivity to the second-line drug, Coartem ® .

malaria journal

Rapid increase of Plasmodium falciparum dhfr/dhps resistant haplotypes, after the adoption of sulphadoxine-pyrimethamine as first line treatment in 2002, in southern Mozambique