|Year : 2017 | Volume
| Issue : 1 | Page : 140-142
Prevalence of multiple drug-resistant Plasmodium falciparum malaria cases in Northeast India
Jitendra Sharma, Siraj Ahmed Khan, Monika Soni, Prafulla Dutta
Regional Medical Research Centre, NER, Dibrugarh, Assam, India
|Date of Web Publication||16-Mar-2017|
Regional Medical Research Centre (ICMR), NER, Dibrugarh, Assam
Source of Support: None, Conflict of Interest: None
Two numbers of Plasmodium falciparum field isolates from Gossingpara, Runikhata area in Chirang district of Assam had shown multiple mutations in Pfcrt-dhfr-dhps gene (up to seven mutations: One mutation in Pfcrt gene, three mutations in Pfdhfr gene and three mutations in Pfdhps gene). Similarly, two cases in Bat camp, Miao area under Changlang district of Arunachal Pradesh had shown a total of eight mutations, of which one mutation in Pfcrt gene, three mutations in Pfdhfr gene, three mutations in Pfdhps gene and one mutation in PfATPase6 gene. One case in 3 Miles, Miao area of Changlang district has shown mutations in Pfcrt(one mutation), Pfdhfr(four mutations) and Pfdhps(three mutations) gene. These results indicated that there is an existence of multiple mutant P. falciparum malaria cases in northeastern region of India.
Keywords: Changlang, Chirang, chloroquine, Plasmodium falciparum
|How to cite this article:|
Sharma J, Khan SA, Soni M, Dutta P. Prevalence of multiple drug-resistant Plasmodium falciparum malaria cases in Northeast India. Indian J Med Microbiol 2017;35:140-2
|How to cite this URL:|
Sharma J, Khan SA, Soni M, Dutta P. Prevalence of multiple drug-resistant Plasmodium falciparum malaria cases in Northeast India. Indian J Med Microbiol [serial online] 2017 [cited 2020 Apr 10];35:140-2. Available from: http://www.ijmm.org/text.asp?2017/35/1/140/202326
| ~ Introduction|| |
Plasmodium falciparum malaria parasites having antimalarial drug resistance capability is a major problem in northeastern (NE) region of India. Earlier studies have reported that antimalarial drug-resistant P. falciparum malaria parasites are circulating in most of the NE states of India. These malaria parasites have shown progressive rise in mutations associated with different antimalarials such as chloroquine (CQ), sulphadoxine-pyrimethamine (SP) and artemisinin., Hence, a molecular surveillance study was carried out in Chirang district of Assam and Changlang district of Arunachal Pradesh to comprehend the response against multiple antimalarial drugs by the malaria parasites.
| ~ Materials and Methods|| |
The study was undertaken in 2012 (from January-December).
Before collection of blood samples, patient consent/assents were taken from all participants. Furthermore, Institutional Ethical permission was obtained from the local health institution.
A total of 93 suspected malaria patients were included in the study, of which 80 cases were from Changlang district of Arunachal Pradesh and remaining 13 cases were from Chirang district of Assam. Two millilitres of blood samples was collected from all the suspected malaria cases.
Detection of malaria parasites
The presence of malaria parasite was confirmed using microscopic slide examination and polymerase chain reaction method.
Amplification of target genes
A partial fragment of 134 bp in P. falciparum CQ resistance transporter (Pfcrt) gene, 648 bp in P. falciparum dihydrofolate reductase (Pfdhfr) gene, 710 bp in P. falciparum dihydropteroate synthase (Pfdhps) gene and 645 bp in P. falciparum ATPase6 gene were amplified and sequenced., Further, single nucleotide polymorphisms were detected by using MEGA5 and DnaSP version v. 5.10.01 software.
| ~ Results|| |
Out of 93 suspected malaria cases, 37 cases were found to be positive for P. falciparum infection. Two numbers of P. falciparum field isolates from Gossingpara, Runikhata area in Chirang district of Assam had shown K76N mutation in Pfcrt gene, N51I+C59R+S108N mutations in Pfdhfr gene and S436A+A437G+K540E in Pfdhps gene. It revealed that these parasite populations are associated with high level of SP drug resistance. The K76T mutations in Pfcrt gene are considered as well established markers of CQ resistance; however such type of mutations were not observed from the above study samples. Furthermore, no mutations in P. falciparum ATPase6 gene, the target site of artemisinin were detected among these isolates.
Again, two cases in Changlang district of Arunachal Pradesh had shown K76I mutation in Pfcrt gene, N51I+C59R+S108N mutation in Pfdhfr gene, S436A+A437G+K540E mutation in Pfdhps gene along with S616F mutation in PfATPase6 gene. Both the cases were observed from Bat camp, Miao area. In contrast, one P. falciparum field isolate from 3 miles, Miao area exhibited K76N single mutation in Pfcrt gene, quadruple mutation N51I+C59R+S108N+I164L in Pfdhfr gene and triple mutation S436A+A437G+K540E in Pfdhps gene. Although, K76N/K76I mutations in Pfcrt gene were observed from few P. falciparum isolates; however, there is no clear evidence regarding the K76N/K76I mutation and CQ resistance.
The epidemiological observation revealed that the study participants were mostly dependent on forest for different activities such as firewood and food. They are supposed to carrying the malaria parasites from forest areas. They were not aware of the transmission and cause of malaria. Furthermore, they are not using mosquito nets during the time of sleeping. All the study participants belong to male category. Low haemoglobin level, mean cell volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration and high platelet distribution widths were recorded amongst the study participants. Normal level of serum ferritin concentration was found in all cases indicating that ferritin has no role in the malaria severity.
| ~ Discussion|| |
Antimalarial resistance-associated mutations in Pfcrt, Pfdhfr and Pfdhps gene were already confirmed by many previous studies in different parts of India.,,,, However, only limited reports are available on multiple drug-resistant malaria parasites having mutations in Pfcrt, Pfdhfr and Pfdhps gene in NE states of India.,,, Our study has revealed multiple mutations in Pfcrt, Pfdhfr and Pfdhps gene, and it confirmed that SP drug will no longer effective in the treatment of malaria cases in these areas. Due to the continuous SP drug pressure, malaria parasites have evolved a certain mechanism to get rid of the toxicity of drugs. Hence, alternative option is needed in this aspect. The government of India has introduced artemisinin-based combination therapy (SP drug along with artemisinin) for the treatment of malaria cases since 2010. However, due to the constant increase in SP resistance P. falciparum malaria parasites in NE states, it is believed that the artemisinin-based combination therapy will be no longer effective for treatment of malaria cases. Interestingly, the K76T mutation in Pfcrt gene was not observed from any of the multiple mutant P. falciparum cases. Instead of that, few novel mutations at 76 codon position in Pfcrt gene (K76N, K76I) were detected. However, it is not clear whether this mutation is associated with CQ resistance or not. Further studies on molecular surveillance along with clinical trial and in vitro tests assays are required in this region to know the role of K76N/K76I mutations in CQ resistance/sensitivity. From this study, it is believed that due to the continuous exposure of SP antimalarials, the parasites have developed resistance competency to it, and at the same time, they response against CQ due to the non-exposure of the drug since a long time. Apart from this, it is very worrying that the same patient has developed mutations in Pfcrt, Pfdhfr, Pfdhps and PfATPase6 together, and it may be associated with resistance to CQ, SP and artemisinin also. Hence, this combination therapy (SP drug along with artemisinin) should be replaced urgently by alternative drugs in those areas. In the same time, the clinicians should also prescribe artemether-lumefantrine combination  (newly introduced by the Government of India in 2013 for NE region) therapy for treatment of P. falciparum malaria cases in NE states of India, especially in most vulnerable areas.
| ~ Conclusion|| |
From the study, it is confirmed that multiple drug-resistant P. falciparum malaria parasites are prevalent in certain parts of NE states in India.
The authors wish to express their gratitude's to the Laboratory staff of Entomology and Filariasis division, Regional Medical Research Centre (ICMR), Dibrugarh for their immense contribution during the research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Sharma YD. Molecular surveillance of drug-resistant malaria in India. Curr Sci 2012;102:696-703.
Ahmed A, Lumb V, Das MK, Dev V, Wajihullah, Sharma YD. Prevalence of mutations associated with higher levels of sulfadoxine-pyrimethamine resistance in Plasmodium falciparum
isolates from Car Nicobar Island and Assam, India. Antimicrob Agents Chemother 2006;50:3934-8.
Gama BE, de Oliveira NK, Zalis MG, de Souza JM, Santos F, Daniel-Ribeiro CT, et al.
Chloroquine and sulphadoxine-pyrimethamine sensitivity of Plasmodium falciparum
parasites in a Brazilian endemic area. Malar J 2009;8:156.
Jelinek T, Rønn AM, Lemnge MM, Curtis J, Mhina J, Duraisingh MT, et al.
Polymorphisms in the dihydrofolate reductase (DHFR) and dihydropteroate synthetase (DHPS) genes of Plasmodium falciparum
and in vivo
resistance to sulphadoxine/pyrimethamine in isolates from Tanzania. Trop Med Int Health 1998;3:605-9.
Cooper RA, Ferdig MT, Su XZ, Ursos LM, Mu J, Nomura T, et al.
Alternative mutations at position 76 of the vacuolar transmembrane protein PfCRT are associated with chloroquine resistance and unique stereospecific quinine and quinidine responses in Plasmodium falciparum
. Mol Pharmacol 2002;61:35-42.
Sharma J, Soni M, Dutta P, Khan SA, Mahanta J. Mutational prevalence of chloroquine resistance transporter gene among Plasmodium falciparum
field isolates in Assam and Arunachal Pradesh, India. Indian J Med Microbiol 2016;34:193-7.
] [Full text]
Sharma J, Dutta P, Khan SA. Population genetic study of Plasmodium falciparum
parasites pertaining to dhps gene sequence in malaria endemic areas of Assam. Indian J Med Microbiol 2015;33:401-5.
] [Full text]
Sharma J, Dutta P, Khan SA, Soni M, Dey D, Mahanta J. Genetic polymorphisms associated with sulphadoxine-pyrimethamine drug resistance among Plasmodium falciparum
field isolates in malaria endemic areas of Assam. J Postgrad Med 2015;61:9-14.
] [Full text]