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Background  Artesunate plus sulfadoxine–pyrimethamine (ASP) is first-line treatment for uncomplicated  Plasmodium falciparum  malaria in most of India, except for six North-eastern provinces where treatment failure rates were high. In Ujjain, central India, the frequency of mutations associated with increased drug tolerance, but not overt resistance to sulfadoxine and pyrimethamine were 9% and > 80%, respectively, in 2009 and 2010, just prior to the introduction of ASP. The frequency of drug resistance associated mutations in Ujjain in 2015–2016 after 3–4 years of ASP use, are reported.    Methods  Blood samples from patients with  P. falciparum  mono-infection verified by microscopy were collected on filter-paper at all nine major pathology laboratories in Ujjain city. Codons  pfdhfr  16–185,  pfdhps  436–632 and K13 407–689 were identified by sequencing.  Pfcrt  K76T and  pfmdr1  N86Y were identified by restriction fragment length polymorphism.    Results  Sulfadoxine–pyrimethamine resistance-associated  pfdhfr  108 N and 59R alleles were found in 100/104 (96%) and 87/91 (96%) samples, respectively.  Pfdhps  437G was found in 10/105 (10%) samples. Double mutant  pfdhfr  59R + 108 N were found in 75/81 (93%) samples. Triple mutant  pfdhfr  59R + 108 N and  pfdhps  437G were found in 6/78 (8%) samples. Chloroquine-resistance-associated  pfcrt  76T was found in 102/102 (100%).  Pfmdr1  N86 and 86Y were identified in 83/115 (72%) and 32/115 (28%) samples, respectively.    Conclusion  The frequency of  P. falciparum  with reduced susceptibility to sulfadoxine–pyrimethamine remained high, but did not appear to have increased significantly since the introduction of ASP. No polymorphisms in K13 associated with decreased artemisinin susceptibility were found. ASP probably remained effective, supporting continued ASP use.

malaria journal

Stable high frequencies of sulfadoxine–pyrimethamine resistance associated mutations and absence of K13 mutations in Plasmodium falciparum 3 and 4 years after the introduction of artesunate plus sulfadoxine–pyrimethamine in Ujjain, Madhya Pradesh, India