Updates on Malaria

Din SyafruddinDepartment of Parasitology, Faculty of Medicine, Hasanuddin University, Makassar 90245

Eijkman Institute for Molecular Biology, Jalan Diponegoro 69, Jakarta 10430, Indonesia Presented on Annual Meeting of PDGKI, Makassar 25 April 2015

Every day is Malaria Day

April 25th marks World Malaria Day, a day to focus on the plight caused by malaria and also the efforts made to control the disease. However, every day is malaria day for half the world, as the disease is a part of their everyday lives. Likewise, for the scientists and organisations working to control and eliminate the disease, malaria is an everyday nemesis. The Every Day is Malaria Day series features some of the research carried out every day around the world on malaria.

Malaria J for World Malaria Day

Introduction

Efforts against malaria has yielded dramatic progress over the last 10-15 years. The scale up of malaria control intervention between 2001-2012 resulted in an estimated 3.3 million lives saved (WHO, 2014).

Malaria-control and management strategies include chemotherapy for patients, indoor residual spraying (IRS), and long-lasting insecticide treated nets (LLINs) to reduce mosquito populations

The spread of parasite and anopheline vector resistance and lack of a efficacious malaria vaccine renew emphasis on development of innovative preventive tools

Global Malaria and Endemicity(WHO malaria report 2014)

Global Distribution of Insecticide resistance

WHO Malaria Report 2014

Life Cycle of the malarial parasite Plasmodium spp

Miller et al, (2002)

Pathogenic basis of malaria

Parasite resistance to Anti malarial drugs

Available antimalarial drugs

cinchona alkaloids quinine 4-aminoquinolines chloroquine, amodiaquine 8-aminoquinolines primaquine, tafenoquine 4-quinoline methanols mefloquine 9-phenanthrene methanols halofantrine

antifolic drugs pyrimethamine, proguanil

sulpha drugs a) sulphones; dapsone b) sulphonamides; sulphadoxine, sulfalene

sesquiterpene lactones a) artemisinin, dihydroartemisinin b) artesunate, artemether, arteether,

antibiotics tetracycline, chloramphenicol, azithromycin,

clindamycin, rifampicin drug combinations pyrimethamine + sulfadoxine ('Fansidar'), atovaquone + proguanil ('Malarone'), Artemisinin-based Combination therapy (ACT): artesute- amodiaquine, dihydroartemisinin-piperaquine, artemether-lumefantrin

Introduced First Report Difference of Resistance (years)

Quinine 1632 1910 278Chloroquine 1945 1957 12Proguanil 1948 1949 1Sulphadoxine- 1967 1967 0pyrimethamineMefloquine 1977 1982 5Atovaquone 1996 1996 0Artemisinin 2000 2009 9

History of antimalarial drug resistance

Mechanism for the antimalarial drug resistance (Borst and Ouellette, 1995)

EIJKMAN INSTITUTE

a. Alteration in drug transport Quinoline antimalarials Artemisinin (?)

b. Alteration in binding affinity to enzyme Antifolates, Sulpha drugs, Coenzyme Q analogues such as atovaquone

Menard et al, 2013

Menard et al, 2013

CO I

CO III

Cytb

6kb

Extrachromosomal genomes in the malarial parasites

Predicted Secondary Structure of the putative apocytochrome b of Plasmodium berghei

Cytoplasmic

H H

H

N

MN

YNSINLVKTHLI

NY

PC

PL N I NF LWN

YG

FL LGI I

F FI

QIL

TG

VF

LA

SR

YS

PEIS

YAYY S I Q H I

LRE

LW

SG

WC

FR

YMA TGA S

LVF F

LT YLH

IL

RGLN

YS Y

LYL

PL

S

WI S GL I IF A L

FI V TA FI GY

V

LPWGQ

MS

YW

GA

TV

I

TN

LL

SG

I

PS

LV

IW L

C

GG

YT

VSDPT

IKR

FF

V

LI

F

AV FP

I C L

IF V

F F I

LH

LH

SGT

NP

L G Y D T A L K I P F YP

NL

LS

LD

VK

GF

NN IL I LF LI

QS IFG VI PL

SH

PD

NA

IV

VN

TY

VT

PL

Q I V PEWY

FL

PFYAML

P

KT

I

SK

NAGL VIV IASL QLL FLL

A

EQ

RN

LT

TI

IQ

F KMV

FS

AR

EY

SF

P

I IW FMC

SFY

A LL W IGC Q L

P Q DIF

IL YGR LF

II LFF SSGL FSL

VQ

KK T H YD

YSS

QANI

Matrix

QoQo

QiQi

NH2

COO-

L

N27, G33, L217 Antimycin AI14, L215 Diuron

50

100

200

250

300

M133I

L144S

V284F

G131, N245, F264 MucidinI141, T142 StigmatellinF123, G131, G137, MyxothiazolY268N

Y268C M133, L144, I258, F267,Y268, L271, K272, P275, G280, L283, V284 Atovaquone

1. Budimulja et al, 1997. Mol. Biochem. Parasitol, 84:137-141.2. Syafruddin et al 1999. Mol Biochem. Parasitol, 104:185-194.3. Siregar et al, 2008. 2008. Parasitol Int, 57:229-232.

Mosquito resistance to insecticide

Available Insecticides I. Sodium channel modulators 1. Pyrethroids: permethrin 2. Pyrethrin: pyrethrin 3. DDT

II. GABA-gated chloride channel inhibitors 1. Cyclodione organochlorine: Chlordane, endosulfan, gamma-HCH

2. Phenylfirazole (Fiproles): Ethiprole, Fipronil

III. Acetyl choline esterase inhibitors: 1. Carbamates: Aldiocarb, bendiocarb etc 2. Triazemates 3. Organophosphate: Acephate, temephos, malathion

Target site mutations

Sodium channel (VGSC) gene mutations confer resistance to DDT and pyrethroid.

Alleles: Wild type at codon 1014 (TTA-Leucine) (kds)

West type resistance (TTT-Phenilalanine) (kdr-w)

East type resistance (TCA-Serine) (kdr-e)

Molecular analyses of GABA Gene Anopheline mosquitoes from Indonesia

Samples collected from collaboration with Indonesia Goverment and Sumba SPIRIT Study supported by GATES Foundation

Study Sites (Province) Species (n)   (%)    Σ = 97 GCA (TCA) (GGA)  WT RT RT

North Molluca An punctulatus 3 3(100%) 0 0Molluca An punctulatus 3 3(100%) 0 0

  An. farauti 5 4(80%) 0 1(20%)North Sumatera An vagus 2 2(100%) 0 0

  An sundaicus 2 2(100%) 0 0Central Java (Purworejo) An vagus 1 0 1(100%) 0

  An aconitus 7 5(71%) 2(29%) 0  An barbirostris 7 6(86%) 1(14%) 0  An balabacensis 5 5(100%) 0 0

Lampung An vagus 6 4(67%) 2(33%) 0  An sundaicus 23 22(96%) 1(4%) 0  An. barbirostris 1 0 1(100%) 0  An kochi 1 0 1(100%) 0

Bangka Belitung An sundaicus 6 6(100%) 0 0  An letifer 2 2(100%) 0 0

East Nusa Tenggara (Sumba) An vagus 3 3(100%) 0 0  An sundaicus 2 2(100%) 0 0  An subpictus 9 9(100%) 0 0  An tesselatus 1 1(100%) 0 0  An minimus 1 1(100%) 0 0  An flavirostris 2 2(100%) 0 0  An indefinitus 3 3(100%) 0 0  An kochi 1 1(100%) 0 0  An maculatus 1 1(100%) 0 0

Study Sites

(%)

G119wild type

119SResistance Type

Lampung 100 0

Purworejo 100 0

North Molluca 100 0

Bangka Belitung 100 0

Molecular analyses of ace1 Gene Anopheline mosquitoes from Indonesia

Samples collected from collaboration with Indonesia Goverment and Sumba SPIRIT Study supported by GATES Foundation

Possible innovative tools

Spatial Repellent is one of the potential tools to explore.

Different from IRS/LLIN, SR does not require a tarsal contact of the vector to chemically-treated surface/space.

The core mechanism of action of an SR approach is inhibition of vector entry into a treated space by a chemical vapor.

Spatial Repellent (SR)

TOXICITY

IRRITANCY

REPELLENCY

Wainyapu Umbungedo All villagesCluster 1

(W1)Cluster 2 (W2) Cluster 3 (U1) Cluster 4 (U2) Cluster 1+4 Cluster 2+3

90% Active+ 10% placebo

10% Active+90% placebo

10% Active+ 90% placebo

90% Active+10%placebo

Active clusters Placebo clusters

HouseholdActive:placebo

108(98:10)

114(11:103)

115(12:103)

108(98:10)

216(196:20)

229(23:206)

Population 368 523 596 633 1001 1119

Samples 42 44 43 41 83 87Malaria incident 26 40 21 5 31 61

Incidence densityPerson-week 652 602 866 888 1540 1468Incidence rate 0.040 0.066 0.024 0.006 0.020 0.042

Without clustering effectRR (95%CI) 0.484 (0.314-0.746)

With clustering effectRR0 (95%CI) 0.484 (0.110-4.839RRM (95%CI) 0.502 (0.018-29.835)RRGM (95%CI) 0.652 (0.088-4.802)

Wainyapu Umbungedo All villagesCluster 1

(W1)Cluster 2 (W2) Cluster 3 (U1) Cluster 4 (U2) Cluster 1+4 Cluster 2+3

90% Active+ 10% placebo

10% Active+90% placebo

10% Active+ 90% placebo

90% Active+10%placebo

Active clusters Placebo clusters

Cumulative incidence

Proportion of Incidence

0.619 0.909 0.488 0.122 0.373 0.701

Without Clustering effectRR (95%CI) 0.533 (0.390 – 0.727)Un-adjusted χ2 18.37 (p < 0.001)

With Clustering effectCluster-specific adjusted χ2 (p –value)

2.356 (p = 0.124)

Pooled adjusted χ2 (p –value) 2.354 (p = 0.125)

Cumulative attack rates of An. sundaicus pooled by village (indoor only)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 260

10

20

30

40

50

60

70

Cumulative Attack in Wainyapu (W1+W2) Indoor Only

Indoor - A.I Indoor - Placebo

Week

Cum

ulati

ve D

ensit

y /

Pers

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 260

0.5

1

1.5

2

2.5

3

3.5

Cumulative Attack in Umbungedo (U1+U2) Indoor Only

Indoor - A.I Indoor - Placebo

Week

Cum

ulati

ve D

ensit

y /

Pers

on

Wilcoxon Paired Test: Statistically different densities between AI vs. Placebo (p=0.0342)

CMLE Rate Ratio: 32.9% reduction in attack rate for a person inside an active coil house (p=0.04388)

Wilcoxon Paired Test: No Significant difference in densities between AI vs. Placebo (p=0.1562)

CMLE Rate Ratio: Not applicable

Spatial Repellent is potential tool to circumvent mosquito

resistance

1. Active mosquito coil in the homes of subjects was associated with a significant protective efficacy (52%) against new infections by plasmodial parasites

2. Reduction in mosquito attack rate might be associated with reduction in malaria attack rates

Malaria and Nutrition

Association between malaria and malnutrition

Is severe malnutrition protective against of malaria?

a) malaria parasites in the blood are known to increase after a re-feeding; b) the findings of autopsy studies; andc) studies on trace elements and C - reactive protein in malaria.

The data could not be proven in later study. Therefore, the relationship is not clearly understood!

Facts:

Malaria and malnutrition act independently, and together are the major cause of morbidity and mortality in the developing countries of the world

Innovations and Recent Developments in Malaria Prevention

Intermittent Preventive treatment in Pregnant women (IPTp)Intermittent Preventive treatment in Children (IPTc)

Study team1. Eijkman Institute for Molecular

Biology, Jakarta, IndonesiaDin Syafruddin*Krisin ChandPuji BS AsihChristian NixonChristina Nixon

2. Eijkman-Oxford Clinical Research Unit, Jakarta, IndonesiaKevin BairdSiti Nurlaela

3. University Hasanuddin, Makassar, IndonesiaDin Syafruddin*Isra WahidHasanuddinJoko HendartoDian Sidik

4. Sumba Foundation, IndonesiaClaus Bogh

5. SOS IndonesiaMichael Bangs

6. Department of Preventive Medicine and Biometrics,Uniformed Services University of the Health Sciences, Bethesda, MD USAJohn GriecoNicole Achee

Thank you