Anti-malarial drug resistance in Africa sparks concern in India

A recent New England Journal of Medicine report titled ‘Evidence of Artemisinin-Resistant Malaria in Africa’ has described two mutations that have been found to resist Artemisinin in northern Uganda, sparking concern in the medical community.

Doctors lean on Artemisinin-based antimalarial drugs as their first choice to treat malaria treatment, especially the Plasmodium falciparum parasite responsible for nearly all global malaria-related deaths. The report from East Africa is of great concern as this drug has saved countless lives all over the world.

India, where malaria is endemic, introduced the Artemisinin-based combination therapy in 2008 after chloroquine failed to successfully treat P. falciparum malaria. The combination was initially introduced in 117 districts with over 90% falciparum burden.

Artesunate plus sulfadoxine-pyrimethamine (AS+SP) became the universal choice for malaria treatment following its introduction in 2010. However, in 2013, artemether-lumefantrine (AL) was introduced as a combination partner following resistance to SP — the partner drug — in India’s seven northeastern states.

Currently, several combinations of derived from Artemisinin are registered in the country.

Failure of Artemisinin-based combination therapy in India
A 2019 report from east India found two mutations in P. falciparum malaria cases that were treated using Artemisinin, linking it to resistance.

In 2021, central India reported the failure of Artemisinin-based combination therapy where SP displayed triple mutations with Artemisinin wild type.

These two reports highlight that the Artemisinin-based combination therapy’s failure might not be linked to Artemisinin alone.

Chloroquine was highly effective to treat malaria in India, but is no longer in use for falciparum malaria.

Though there have been reports of P. vivax malaria resisting chloroquine, this drug remains an effective choice for this species’ treatment.

Drug resistance history
Chloroquine resistance first came to light in the 1950s. Resistance to pyrimethamine and chloroquine first emerged in Southeast Asia, then migrated to India, followed by Africa.

Similarly, resistance to Artemisinin also developed from six Southeast Asian countries before migrating. It would seem that Artemisinin is taking the same path as chloroquine.

Medical experts are now calling for Molecular Malaria Surveillance to isolate the drug-resistant variants in order to take corrective measures to avoid future consequences. In an effort to make the partner drug less effective, some medical experts have even advocated using triple Artemisinin-based combination therapies.