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Background  The malaria situation has been worsening in Angola, partly due to armed conflict until the recent past and drug-resistant  Plasmodium falciparum . Malaria transmission is heterogeneous within the country, and data on drug-resistant malaria in different parts of the country are incomplete. The aim of the present study was to evaluate resistance to 4-aminoquinolines and antifolate drugs in  P. falciparum  isolates collected in Benguela province, central Angola, using molecular markers.    Methods  Fingerprick capillary blood was collected from asymptomatic children aged less than 15 years old during a household survey in and around Balombo town in 2010–2011. Samples were screened for  P. falciparum  by nested PCR. Molecular markers ( P. falciparum  dihydrofolate reductase [ pfdhfr ],  P. falciparum  dihydropteroate synthase [ pfdhps ],  P. falciparum  chloroquine resistance transporter [ pfcrt ], and  P. falciparum  multidrug-resistance gene 1 [ pfmdr1 ]) were sequenced to determine the key codons associated with drug resistance.    Results  A total of 60 blood samples were positive for  P. falciparum . Most isolates with successful PCR amplification had mutant  pfdhfr  alleles, with either double mutant AICNI (69%) or triple mutant AIRNI (21%) haplotypes. A16V, S108T, and I164L substitutions were not found. Many of the isolates were carriers of either SGKAA (60%) or AGKAA (27%)  pfdhps  haplotype. K540E substitution was absent. There were only two  pfcrt  haplotypes: wild-type CVMNK (11%) and mutant CVIET (89%). Wild-type  pfmdr1  NYSND haplotype was found in 19% of the isolates, whereas single mutant  pfmdr1  YYSND and NFSND haplotypes occurred in 48% and 11%, respectively. Double mutant  pfmdr1  haplotypes (YFSND and YYSNY) occurred rarely.    Conclusions  The results suggest that the high prevalence of mutant  pfcrt  CVIET haplotype is in agreement with low clinical efficacy of chloroquine observed in earlier studies and that the double  pfdhfr  mutant A I C N I and single  pfdhps  mutant SGKAA are currently the predominant haplotypes associated with antifolate resistance in Benguela province. The hallmark of clinical resistance observed in East Africa, i.e. triple  pfdhfr  mutant haplotype (AIRNI) and double  pfdhps  mutant haplotype (SGEAA), was absent. These molecular findings need to be further evaluated in parallel with clinical studies, in particular with the efficacy of intermittent preventive treatment using sulphadoxine-pyrimethamine in pregnant women and artesunate-amodiaquine for uncomplicated malaria.

Molecular epidemiology of drug-resistant Plasmodium falciparum in Benguela province, Angola