Antimalarial Drug Resistance in India

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    In News

    • Recently, the New England Journal of Medicine published an article `Evidence of Artemisinin-Resistant Malaria in Africa’.
      • It confirmed the increasing evidence for the failure of artemisinin-based combination therapy for falciparum malaria either alone or with partner drugs.

    Malaria

    • Malaria is mosquito borne blood disease caused by plasmodium protozoa.
      • The parasites spread through the bites of infected female Anopheles mosquitoes.
      • It is preventable as well as curable but can be fatal in case of late or no treatment.
    • Mechanism of action
      • Plasmodium needs two hosts to complete its life cycle.
      • After entering the human body, parasites initially multiply within the liver cells 
      • Then it attacks the Red Blood Cells (RBCs) resulting in their rupture.

    Courtesy: IndiaToday

    • Protozoa
      • There are 5 Plasmodium protozoa species that cause malaria in humans
      • Two of these species which pose  the greatest threat are.
        • Plasmodium falciparum and 
        • Plasmodium vivax
    • Disease Prevalence
      • It is predominantly found in the tropical and subtropical areas of Africa, South America as well as Asia.
      • Amongst India’s Neighbours, China was recently declared Malaria free by WHO.
    • Symptoms
      • Fever and flu-like illness, including shaking chills, headache, muscle aches, and tiredness.

    Malaria Burden in India

    • The World Malaria Report (WMR) 2020 released by WHO gives the estimated cases for malaria across the world.
    • It indicates that India has made considerable progress in reducing its malaria burden.
    • India is the only highly endemic country which has reported a decline of 17.6% in 2019 as compared to 2018.

    Malaria Vaccine

    • Mosquitrix or RTS,S
      • This vaccine has been branded as Mosquirix but is also known by its lab initials as RTS,S.
      • It was developed by GlaxoSmithKline (GSK) company and approved by the European Medicines Agency in 2015.
      • The vaccine has shown a maximum efficiency of nearly 40%.
    • R21/ Matrix M
      • Still under trial stage but may be 77% effective.

    Recent Report of Antimalarial Drug Resistance

    • In most malaria-endemic countries including India, Artemisinin-based antimalarial drugs are the first-line choice for malaria treatment.
      • They are especially effective against Plasmodium falciparum.
    • The study ‘Evidence of Artemisinin-Resistant Malaria in Africa’ described the presence of two mutations responsible for artemisinin resistance in Northern Uganda.
      • The report of artemisinin resistance in East Africa is a matter of great concern because 
        • This is the only drug that has saved several lives across the globe.

    History of Drug Resistance

    • In the 1950s, chloroquine resistance came to light. 
    • Both chloroquine and pyrimethamine resistance originated from Southeast Asia 
    • From there they migrated to India and then on to Africa with disastrous consequences.
    • Similarly, artemisinin resistance developed from the six Southeast Asian countries and migrated to other continents, as is reported in India and Africa.
    • It would not be out of context that artemisinin is following the same path as has been seen with chloroquine.

    Artemisinin-based combination therapy failure in India

    • In India, after the chloroquine resistance was seen in P. falciparum, artemisinin-based combination therapy was introduced in 2008.
    • In 2010, artesunate plus sulfadoxine-pyrimethamine (AS+SP) was introduced universally.
    • In 2013, in view of resistance to the partner drug SP in the 7 North Eastern States, 
      • The combination partner was replaced by artemether- lumefantrine (AL) for these states.
    • In 2019, Eastern India indicated the presence of 2 mutations in P. falciparum treated with artemisinin that linked to its presence of resistance.
    • Again in 2021, artemisinin-based combination therapy failure was reported from Central India.
      • Here too the partner drug SP showed triple mutations with artemisinin wild type.
    • This means the failure of artemisinin-based combination therapy may not be solely linked to artemisinin. 
      • Here it is needed to change the partner drug as has been done in NE states in 2013 and subsequent cases.
    • Currently, several combinations of artemisinin derivatives are registered in India.

    Conclusion and Way Forward

    • Monitor Chloroquine resistance in P. Vivax
      • Though there have been some reports of chloroquine resistance in P. vivax malaria, this drug is still the effective choice to treat this species.
      • Continued monitoring is needed.
    • Molecular Malaria Surveillance
      • The time has come to carry out Molecular Malaria Surveillance to find out the drug-resistant variants.
        • It will help in undertaking corrective measures in time to avert any consequences.

    Few Initiatives related to Malaria

    • Initiatives of WHO
      • Celebration of World Malaria Day on 25th April every year. 
        • The 2021 theme is “Reaching the Zero Malaria target”.
      • ‘E-2025 Initiative’
        • The WHO has also identified 25 countries with the potential to eradicate malaria by 2025 under its ‘E-2025 Initiative’.
    • Indian Initiatives
      • 5 year National Strategic Plan for Malaria Elimination
        • Launched in 2017
        • It shifted focus from Malaria control to elimination.
        • It provided a roadmap to end malaria in 571 districts out of India’s 678 districts by 2022.
      • Malaria Elimination Research Alliance-India (MERA-India)
        • Established by Indian Council of Medical Research (ICMR)
        • It is a conglomeration of partners working on malaria control.

    Source: IE