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Daena: International Journal of Good Conscience. A1.17(3)1-18. November 2022. ISSN 1870-557X
Resistance to Artemisinins in Africa and the WHO
Reservations About use of A. annua in Africa
Munyangi wa Nkola Jerome MD, Msc, MPH
Faculté de Médecine Université de Kolwezi , Departement des Sciences Bio-Médicales, Kolwezi , République Démocartique du Congo ; Laboratoire des
Produits Naturels , Fondation Dr Munyangi , Kinshasa , République Démocratique du Congo
Email: jwankola5@gmail.com
Abstract
Artemisinin resistance was first identified in Cambodia in 2008. In the Mekong region, once
artemisinin resistance has spread widely, it is often followed by resistance to its associated
drugs, leading to failure of combination therapy. This resistance is associated with para-
sites carrying genetic mutations. Despite a denial of resistance to artemisinin and other
antimalarials in Africa by the World Health Organization and other institutions such as the
Pasteur Institute, health professionals are still alerted to this resistance.
In this article, we present a non-exhaustive literature on the reports of resistance to Arte-
misinin and other antimalarials in Africa.
The researchers point out that the emergence of partial artemisinin resistance in Africa is
an alarm of a great public health danger, if these resistance to related drugs spread rapidly
in Africa, the effectiveness of treatment could be compromised. Recent data from Africa
suggest that we are on the verge of clinically significant artemisinin resistance.
That African policy makers and researchers reflect on alternative malaria treatments in
Africa. We need to accelerate research on medicinal plants including Artemisia annua and
afra in Africa.
Keywords
ACTs, Alu, K13 , ASAQ, WHO,
2
1. Introduction
According to the WHO World Malaria Report (2021), there were approximately 241 million malaria cases and 627,000 malaria deaths
worldwide in 2020. This represents approximately 14 million more cases in 2020 than in 2019 and 69,000 more deaths. About two-
thirds of these additional deaths (47,000) were related to
disruptions in the delivery of malaria prevention, diagnosis, and treatment during the during the pandemic (1).
The report shows that Africa has the highest malaria burden in the world. 95% of cases and 96% of deaths are concentrated in sub-
Saharan Africa, and 80% of malaria malaria deaths in Africa occur in children under five years of age (2).
One of the major challenges in the fight against malaria that the scientific community has to face is the great ability of P. falciparum to
develop resistance mechanisms against the molecules that are submitted to it. Indeed, over the years, P. falciparum has become
resistant to almost all the antimalarial drugs that have been used [3].
In order to contain and prevent this growing phenomenon of chemoresistance, the WHO recommends the use of drug combinations,
one of the molecules of which should be artemisinin (or derivatives) [ 4].
To this end, the DRC adopted in 2005, like most endemic countries, the use of artemisinin-based combination therapies (ACTs) for the
first-line treatment of malaria. To date, two combinations have been validated by the Ministry of Health and are used: Artesunate-
Amodiaquine (ASAQ) and Artemether-Lumefantrine (ALu).
Artemisinin, a molecule that allows rapid clearance of parasites from the bloodstream, has begun to lose its effectiveness, as have the
other antimalarial molecules used previously. To date, this resistance remains confined to Southeast Asia, more precisely to the Greater
Mekong region [5-6]. All experts agree that the spread of this resistance to the African region would be catastrophic.
The discovery of a molecular marker for artemisinin resistance in 2004 by Ariey et al [7] offers the possibility to periodically monitor the
emergence of artemisinin resistance in Africa. Numerous studies have been carried out to explore the presence or appearance of
artemisinin-resistant mutant strains in some African countries, but fortunately none of the "Asian" mutations conferring resistance have
been found [ 7-8].
Artemisinin resistance in P. falciparum is asso- ciated with pfkelch13 polymorphisms encoding the parasite’s Kelch 13 (K13) propeller
domain, which consequently serve as a molecular marker in sur- veillance (9)
In a study of Edwin and all , the prevalence of K13-propeller mutations in sub-Saharan Africa was described on samples collected in
several countries . This baseline information will be essential for monitoring the emergence and/or spread of P. falciparum artemisinin
resistance in sub-Saharan Africa [10].
This study observed an urgent and important need for local studies of clinical artemisinin resistance and in vitro and ex vivo RSA0-3
hour data to clarify the significance of K13 helix mutations as markers of artemisinin resistance Africa. [10].
3
Fig.1. Map of worlwide artemisinin resistance (Kelch13 mutations) (11)
Republic Democratic of Congo, DRC Resistance
A systematic review paper from RDCongo found 5 resistance genes related to ACT tratment.
The review of Mvumbi et al , articles were classified based on year of collecting, year of publication, sample size and
characteristics, molecular markers analysed and polymorphisms detected.
Some of them concerned non-Congolese individuals but supposedly infected in DRC. Five genes were analyzed in
these studies: the Plasmodium falciparum chloroquine resistance transporter gene (pfcrt), the dihydropteroate syn-
thase gene (pfdhps), the dihydrofolate reductase gene (pfdhfr), the Plasmodium falciparum multidrug resistance 1
gene (pfmdr1), and the K13 propellant gene (k13) (12).
Uganda Resistance
Several reports from African health professionals confirm this dramatic situation of antimalarial ineffectiveness.
The Kiguba (Uganda) article confirms that one in five health professionals reported suspected or confirmed therapeutic
ineffectiveness of ACT treatment to at least one competent authority in the previous six months, whist is significantly
higher than the documented extent of adverse event reporting by health professionals in the same setting . (13)
In Uganda an independent selection was identified of three polymorphisms in the pfmdr1 gene following administration
of AL in a region of Africa where malaria is highly endemic. These polymorphisms were not associated with clinical
treatment failure but are evidence for the ability of this drug combination to drive selection of parasites toward resistant
phenotypes. These polymorphisms were not associated with clinical treatment failure, but provide evidence of the
ability of this drug combination to drive parasite selection towards resistant phenotypes. (14)
4
Fig.2. Prevalence of pfmdr1 alleles in pretreatment samples and samples from newly infected patients following
therapy with artemether-lumefantrine. Alleles typically classified as wild type are on the left, mixed infections
are in the middle, and those classified as mutant are on the right.
In Uganda Plasmodium genotypes with decreased sensitivity to artemether-lumefantrine increased from 2008 to 2012
in a study involving 312 children. Another trial reports failures in artemether-lumefantrine treatment (15 -16 ).
Another clinical trial with artemether-lumefantrine in Uganda gave catastrophic results: Late parasitological failure 137
(32.9%), Late clinical failure 74 (17.8%) 7 (2.0%). Adequate clinical and parasitological response 189 (45.4%) (17).
5
Nigeria Resistance
At the top of the list of the most affected countries, Nigeria accounted for 26.8% of patients in 2020. The country also
has the highest mortality rate with 31.9%. This is more than double that of the Democratic Republic of Congo (13.2%),
the second most affected nation by this disease, to which children under five and pregnant women are very vulnerable.
A study Monday Tola , describes mutations in Plasmodium falciparum genes associated with drug resistance in ma-
laria; Pfk13, Pfmdr1, PfATPase6 and Pfcrt in isolates obtained from 83 symptomatic malaria patients collected in Au-
gust 2014, aged 1-61 years in southwest Nigeria.
In Nigeria they find that some Pfmdr variants are present at a prevalence of 56%. (18)
Fig.3. Allelic discrimination of wild and mutant genes in parasite samples (a) Pfk13 SNP580 and
(b) PfATPase SNP402. DNA from dried blood spots (DBS) were extracted and used for TaqMan allele discrimina-
tion assays. Blue points depict wild type alleles, green for mixed allele calls and orange for mutant variants. Un-
typed reactions are shown in black.
In Nigeria a study reveals a need to re-evaluate the quality and efficacy of artemisinin-based combination therapy
agents in Nigeria and Sub-Saharan Africa. Though six ACT combination therapies are available, but malaria is re-
sistant to one of the longer-acting drugs and patients had bad reactions to another, so only four ACTs are recom-
mended. Christian Happi, a malaria of Redeemer's University in Lagos declares that among thousands of blood sam-
ples anlyzed 80–90% have at least one mutation. (19,20,21,22)
Angola Resistance
In a study in Angola, The results of the pfcrt and pfmdr1 sequence analyses were consistent with the literature showing
an overrepresentation of the 76T pfcrt allele in amodiaquine treatment failures and a predominance of the N86 pfmdr1
allele in AL treatment failures and confirms the high prevalence of the N86 allele in the circulating parasite population
in Angola and the high prevalence of the N86 allele even in the ASAQ treatment failures in this study. Notably, the
fixation or near fixation of the N86 allele, as well as clinical evidence of reduced efficacy, may have implications for the
future of LA use in Angola. (23)
In Angola resistance to lumefantrine and artemisinine derivatives was extensively studied. (24)
6
But some French experts refuse to recognize these facts. If an African medical doctor publishes a scientific paper
describing the shorthcomings of ACTs, their reaction is violent and obnoquious. They even ask the scientific journal to
retract the published paper.
Finally, after so much evidence accumulated in many African countries, WHO and Pasteur also recognize that ACT
resistance spreads in Africa, in this case Rwanda. Idem a German team.
Rwanda Resistance
In this Rwandan genomics study, Rwandan Pfkelch13 561H mutants were phylogenetically related to other African
samples and clustered unambiguously with Rwandan Pfkelch13 WT parasites. Haplotype analysis revealed that the
Rwandan Pfkelch13 561H mutants shared an identical haplotype surrounding the R561H mutation that differed from
the haplotypes of the SEA 561H mutants, strongly suggesting a unique de novo epidemiological origin and recent
spread of the mutation. But which had no genetic relationship to the Pfkelch13 561H mutants detected in Myanmar
and Thailand.(25)
Principal Coordinate Analysis (PCoA) based on pairwise genetic distances in a 494 kb window around
the Pfkelch13gene.
Fig. 4. Principal Coordinate Analysis including Pfkelch13 wild type and 561H isolates including those sourced from
a public database (small dots, the MalariaGEN Plasmodium falciparum Community Project, https://www.ma-
lariagen.net/apps/pf/4.0)and originating from different continents (Asia, Africa or South America). Isolates origi-
nating from populations where the Pfkelch13 R561H mutation was found are emphasized (large dots). Empty
large dots correspond to Pfkelch13 wild-type isolates and filled large dots correspond to Pfkelch13 561H mutants.
While the mutants tend to cluster with individuals of similar origin, axis 1 clearly discriminates African (Rwanda)
from Asian (Thailand and Myanmar) Pfkelch13 561H mutants.
7
Another study from Rwanda confirm the presence of K13 mutations are Rwanda and that their prevalence in P. falci-
parum malaria patients in Huye district has increased from 0% in 2010 to >12% in 2019. The validated artemisinin
resistance mutation R561H is present in 4.5% of P. falciparum isolates transmitted in this region. The emergence of
artemisinin resistance mutations in Rwanda is alarming as it may indicate the development of resistance to commonly
used antimalarial drugs in this region. (26)
Tanzania Resistance
Also, in the neigboring country, Tanzania, known drug resistance mutations were seen at increased frequency in north-
ern districts
In a Tanzanian study that separated northern and southern districts and identified genetically mixed populations in
the north. Isolates from nearby districts were more likely to be genetically related than parasites collected from more
distant districts. Known drug resistance mutations were observed at increased frequency in northern districts (includ-
ing two infections carrying pfk13-R561H), and additional variants of undetermined significance for antimalarial drug
resistance also varied by geography.(27)
In Tanzania the overall prevalence of NFD haplotype claimed to be associated with emerging artemether-lumefantrine
tolerance ranges from 17 to 26% among other haplotypes. With continuation of ALu as first-line drug and in the absence
of CQ and AQ, this haplotype is expected to keep rising. There is need for continued pharmacovigilance studies in
order to predict early parasite tolerance to the drug.(28)
In Tanzania the temporal selection of molecular markers associated with artemether-lumefantrine tolerance/resistance
may represent an early warning sign of impaired future drug efficacy. This calls for stringent surveillance of artemether-
lumefantrine efficacy and emphasizes the importance of molecular surveillance as a complement to standard in vivo
trials.(29)
In Tanzania the difference between individual treatment groups and the next best treatment combination was significant
(p<0.001) in every case. Recrudescence rates by day 28, after correction by genotyping, were 48.4%, 34.5%, 11.2%,
and 2.8%, respectively. The study shows how few the options are for treating malaria where there is already a high
level of resistance to sulfadoxine-pyrimethamine and amodiaquine. (30)
In Tanzania a study suggested that drug pressure selection for increased parasite virulence and infectiousness may
be occuring in human populations in Africa.(31,32)
In a recent study in Tanzania a wide range of pfk13 transcript variation was observed throughout all timepoints after
artemether-lumefantrine treatment. The findings suggest that a reduced PfK13 transcriptional response may represent
a first step towards artemisinin tolerance/resistance. (33)
Over the last century all monotherapies (quinine, chloroquine, mefloquine, lumefantrine, piperaquine, pyrimethamine,
halofantrine) have led to rapid resistances of Plasmodium falciparum. Combination therapy between artemisinin and
molecules with long lasting action had raised optimism. But already in 2003 first signs of resistance developed in South-
East Asia. It has been established meanwhile that they were mostly related to mutations in the kelch13 propeller region
of the parasite. Mutations have meanwhile raised to 90%. (34)
8
Fig.5. Evolution de la Chimionsebilité P.f.
Artemisinin resistance in Plasmodium falciparum has emerged in South-East Asia, has spread over several countries
and now poses a threat to the control and elimination of malaria.
But the problem is not limited to South-East Asia. Signs of arteminisin resistance have developed in other continents,
in at least a dozen African countries.
Researchers from the London School of Hygiene and Tropical Medicine have discovered a new genetic mutation in
Plasmodium falciparum, the parasite that causes malaria, which may mean the A recent review identified emergence
of potential ART-resistance mediating k13 mutations in the African region. Diversity of mutations in pfkelch13 gene is
high in African region.
Kenya Resistance
In Kenya authors conclude that parasite clearance time after artemisinin-based combination therapy (ACT) may be
increasing in Asian and African settings.(35)
On the Kenyan coast the significant, albeit small, decline through time of parasitological response rates to treatment
with ACTs may be due to the emergence of parasites with reduced drug sensitivity,(36)
In Kenya the findings of another research team call for close monitoring of parasite genotypic, phenotypic and clinical
dynamics in response to current first-line treatment in western Kenya. Having been the first focus of chloroquine re-
sistance in Africa western Kenya will be crucial in informing the next steps on the deployment of first-line treatment of
uncomplicated malaria in the possible future era of attenuated response of artemisinin.(37)
In a malaria endemic area in Kenya a K13 propeller sequence analysis of P. falciparum parasites Kenya did not detect
the predicted artemisinin-resistant genotypes, but some temporal substitutions were observed(38, 39)
9
Impact of pre-existing immunity on artemisinin combination therapy (ACT) efficacy was examined in Kenya to monitor
resistance, and for implementation of new treatment strategies. The number of individuals with lag phase was signifi-
cantly higher in the Artemether-Lumefantrine compared to the Artesunate-Amodiaquine (40)
Mali Resistance
In Mali K13-propeller mutations were identified in both recent samples and pre-ACT infections.
In Mali a study by Ouattara concluded that K13-propeller mutations can occur at a low frequency, independent of drug
selection by artemisinin treatment or possibly, selection pressure by other drugs (e.g., chloroquine). K13-propellant
proteins have been associated with reduction and oxidation stress management (REDOX) of the cell,16,17 a type of
effect characteristic of the action of most antimalarial drugs on P. falciparum, including chloroquine.18 The manage-
ment of stress or the effect of other drugs in the selection of K13-propellant mutations and the relevance, if any, of
these K13-propellant mutations on artemisinin efficacy will require further investigation, including genetic transfor-
mation studies(41)
Senegal Resistance
In Senegal the increased prevalence of Pfmdr1 duplication in P. falciparum isolates from patients in Dakar within a 2-
year period is cause for concern and vigilance (42)
Sudan Resistance
In Sudan the findings of a study call for a need to review the Sudan malaria treatment policy. Epidemiological factors
could play a major role in the emergence of drug-resistant malaria in eastern Sudan.
In this study a total of 371 pre-treatment samples were analyzed for molecular markers of MS resistance. Temporal
changes and geographic differences in the frequency distribution of MS resistance genotypes showed evidence of
regional differentiation and selection of resistant strains. The results of this study call for the need to review the malaria
treatment policy in Sudan. Epidemiological factors may play a major role in the emergence of drug-resistant malaria in
eastern Sudan.(43)
10
Fig 6: High efficacy of artemether-lumefantrine and declining efficacy of artesunate + sulfadoxine-py-
rimethamine against Plasmodium falciparum in Sudan (2010–2015): evidence from in vivo and molecular
marker studies
Liberia Resistance
In Liberia it was found that although treatment is highly efficacious, selection of molecular markers in reinfections could
indicate a decreased sensitivity or tolerance of parasites to the current treatments and the baseline prevalence of
molecular markers should be closely monitored (44).
Ghana Resistance
In Ghana the persistent detection of low density Plasmodium sp. Infections, following antimalarial treatment suggests
these may be a hitherto unrecognised obstacle to malaria elimination. The presence of variants of the validated mark-
ers of artemisinin resistance as well as persisting polymorphisms after 14 years of artemisinin-based combination
therapy use argues for continuous surveillance of the markers. In another study in Ghana a high prevalence of ASAQ
resistant parasites was already noticed in 2008.(45,46.47)
Ethiopia Resistance
In Ethiopia high rates of recurrent parasitemia were noted for AL and CQ against Plasmodium vivax less frequently
against Plasmodium falciparum (48,49 )
Somalia Resistance
In Somalia a failing first-line treatment (AS + SP), with a failure rate above the threshold (10%) for policy change, and
a high prevalence of quintuple mutations were found; (50)
11
Mozambique Resistance
In Mozambique, after the decrease in clinical malaria incidence observed until 2009, a steady resurgence of cases per
year has been reported nationally, reaching alarming levels in 2014.(51)
Gabon Resistance
In Gabon severe artemisin resistance was noticed.(52). In Gabon another study confirms these intriguing results. The
strongest correlation between diminished DHA sensitivity and MF resistance was observed, followed by correlation
between diminished DHA sensitivity and CQ resistance. Cross-resistance between CQ and MF was also observed.(53)
In Gabon a study shows an increase in the prevalence of childhood plasmodial infection and a high frequency of
markers associated with AL treatment failure.(54)
Burkina Faso Resistance
In Burkina Faso clinical trial NCT00808951 shows a higher occurrence of recurrent malaria infections during a 28-day
follow up period for artemether-lumefantrine. Already at the MIM 2009 conference at Nairobi it was stated that 3 years
after the ACT introduction there are concerns about the decrease level of theses ACTs efficacy. The risk of treatment
failure was already 29,2 % for artemether-lumefantrine.(55)
In a recent trial in Burkina Faso there is a lowering of the cure rate after ACT treatment and around 50% of the treated
patients develop a new malaria episode within 28 days
Fig 6. Temporal variation of PCR uncorrected Adequate Clinical and Parasitological Response by treat-
ment group(56)
Artemisia annua and the WHO reservations use in Africa
Artemisinin, the central molecule of the current antimalarial strategy, is produced from the leaves of the annual mugwort
or Artemisia Annua. This plant has been widely used for almost two millennia in the Chinese pharmacopoeia [57]. The
use of ACTs recommended by the WHO is nevertheless subject to certain constraints constraints specific to artemisinin
such as: the counterfeiting of antimalarial molecules molecules marketed in Africa [58-59], the long duration for culti-
vation, extraction, processing and manufacturing of the final product, the complexity of manufacturing operations and
12
quality control, but also the relatively high relatively high cost [60]. Many studies have been conducted to assess the
appropriateness of this practice and opinions are so far very mixed in the scientific community.
On the one hand, Diawara HZ et al. report an efficiency rate > 95% of herbal tea d'Artemisia annua L. sur P. falciparum
[61]; Munyangi et al. conclude in their study that infusions based on A. annua and A. afra would confer better results
that the combination ASAQ [62]. Weathers et al. on the other hand argue for the inclusion of A. annua dried leaf tablets
in the arsenal antimalarial therapy [63].
On the other hand, the results of Mueller et al. which describe high rates of recrudescence after use of herbal teas
based on A. annua, thus advise against the use of A. annua as an alternative to antimalarial drugs [64]; the WHO also
gives its position stating that it does not recommend the use A. annua in all its forms for the treatment or prevention of
malaria [65]; in France, the National Agency for Drug Safety (ANSM) suspended the placing on the market of a product
called Artemisia [66] and the National Academy of Medicine (ANM) has issued a statement warning health authorities
and populations of malaria transmission areas on recommendations scientifically uncertain and irresponsible for the
use of this herbal medicine” [67. An online survey conducted by Malaria World (a platform of experts in the field) yields
32% vs 68% respectively for people favorable to the use of herbal teas based on A. annua and for those who are there
oppose [68].
One of the main reasons cited by those who advise against the use of herbal teas based on A. annua is the probability
of emergence of strains resistant to artemisinin following continuous low-dose administration.
However, to date, no scientific work has shown a clear correlation A. annua herbal tea and resistance to artemisinin.
Conclusion and Suggestions
In this paper, we have attempted to present a current assessment of our knowledge of resistance to artemisinin and
its derivatives in Plasmodium falciparum in Africa, with emphasis on molecular studies and factors affecting its distri-
bution in endemic populations.
It remains surprising that, despite the studies on these phenomena of antimalarial drug resistance, African govern-
ments do not disclose any research to seek alternative solutions to the current treatments of malaria.
We suggest and encourage the acceleration of research on African medicinal plants including clinical research on
Artemisia in Africa.
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