Prevalence of antifolate drug resistance markers in Plasmodium vivax in China

Abstract

The dihydrofolate reductase (dhfr) and dihydropteroate synthetase (dhps) genes of Plasmodium vivax, as antifolate resistance-associated genes were used for drug resistance surveillance. A total of 375 P. vivax isolates collected from different geographical locations in China in 2009–2019 were used to sequence Pvdhfr and Pvdhps. The majority of the isolates harbored a mutant type allele for Pvdhfr (94.5%) and Pvdhps (68.2%). The most predominant point mutations were S117T/N (77.7%) in Pvdhfr and A383G (66.8%) in Pvdhps. Amino acid changes were identified at nine residues in Pvdhfr. A quadruple-mutant haplotype at 57, 58, 61, and 117 was the most frequent (57.4%) among 16 distinct Pvdhfr haplotypes. Mutations in Pvdhps were detected at six codons, and the double-mutant A383G/A553G was the most prevalent (39.3%). Pvdhfr exhibited a higher mutation prevalence and greater diversity than Pvdhps in China. Most isolates from Yunnan carried multiple mutant haplotypes, while the majority of samples from temperate regions and Hainan Island harbored the wild type or single mutant type. This study indicated that the antifolate resistance levels of P. vivax parasites were different across China and molecular markers could be used to rapidly monitor drug resistance. Results provided evidence for updating national drug policy and treatment guidelines.

Keywords

drug resistance / antifolates / molecular markers / Plasmodium vivax / China

References

[1] Price RN, Commons RJ, Battle KE, Thriemer K, Mendis K. Plasmodium vivax in the era of the shrinking P. falciparum map. Trends Parasitol 2020; 36(6): 560–570

[2] World Health Organization. World malaria report 2020. Geneva: WHO, 2020

[3] Zhang HW, Liu Y, Zhang SS, Xu BL, Li WD, Tang JH, Zhou SS, Huang F. Preparation of malaria resurgence in China: case study of vivax malaria re-emergence and outbreak in Huang-Huai Plain in 2006. Adv Parasitol 2014; 86: 205–230

[4] Zhang S, Guo S, Feng X, Afelt A, Frutos R, Zhou S, Manguin S. Anopheles vectors in mainland China while approaching malaria elimination. Trends Parasitol 2017; 33(11): 889–900

[5] Zhou SS, Huang F, Wang JJ, Zhang SS, Su YP, Tang LH. Geographical, meteorological and vectorial factors related to malaria re-emergence in Huang-Huai River of central China. Malar J 2010; 9(1): 337

[6] Nzila A. The past, present and future of antifolates in the treatment of Plasmodium falciparum infection. J Antimicrob Chemother 2006; 57(6): 1043–1054

[7] World Health Organization. Implementing malaria in pregnancy programs in the context of World Health Organization recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO, 2018

[8] World Health Organization. Intermittent preventive treatment for infants using sulfadoxinepyrimethamine (SP-IPTi) for malaria control in Africa: Implementation field guide. Geneva: WHO, 2011

[9] World Health Organization. World malaria report 2019. Geneva: WHO, 2019

[10] Mohamed NS, Abdelbagi H, Osman HA, Ahmed AE, Yousif AM, Edris YB, Osman EY, Elsadig AR, Siddig EE, Mustafa M, Mohammed AA, Ali Y, Osman MM, Ali MS, Omer RA, Ahmed A, Sibley CH. A snapshot of Plasmodium falciparum malaria drug resistance markers in Sudan: a pilot study. BMC Res Notes 2020; 13(1): 512

[11] Huang B, Huang S, Su XZ, Tong X, Yan J, Li H, Lu F. Molecular surveillance of pvdhfr, pvdhps, and pvmdr-1 mutations in Plasmodium vivax isolates from Yunnan and Anhui provinces of China. Malar J 2014; 13(1): 346

[12] Huang F, Zhou S, Zhang S, Li W, Zhang H. Monitoring resistance of Plasmdium vivax: point mutations in dihydrofolate reductase gene in isolates from Central China. Parasit Vectors 2011; 4(1): 80

[13] National Health Commission of the People’s Republic of China. Technical regulations for application of antimalarials (WS/T 485-2016). 2016

[14] Imwong M, Pukrittakayamee S, Looareesuwan S, Pasvol G, Poirreiz J, White NJ, Snounou G. Association of genetic mutations in Plasmodium vivax dhfr with resistance to sulfadoxine-pyrimethamine: geographical and clinical correlates. Antimicrob Agents Chemother 2001; 45(11): 3122–3127

[15] Imwong M, Pukrittayakamee S, Rénia L, Letourneur F, Charlieu JP, Leartsakulpanich U, Looareesuwan S, White NJ, Snounou G. Novel point mutations in the dihydrofolate reductase gene of Plasmodium vivax: evidence for sequential selection by drug pressure. Antimicrob Agents Chemother 2003; 47(5): 1514–1521

[16] Thongdee P, Kuesap J, Rungsihirunrat K, Tippawangkosol P, Mungthin M, Na-Bangchang K. Distribution of dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) mutant alleles in Plasmodium vivax isolates from Thailand. Acta Trop 2013; 128(1): 137–143

[17] Tantiamornkul K, Pumpaibool T, Piriyapongsa J, Culleton R, Lek-Uthai U. The prevalence of molecular markers of drug resistance in Plasmodium vivax from the border regions of Thailand in 2008 and 2014. Int J Parasitol Drugs Drug Resist 2018; 8(2): 229–237

[18] de Pécoulas PE, Tahar R, Yi P, Thai KH, Basco LK. Genetic variation of the dihydrofolate reductase gene in Plasmodium vivax in Snoul, northeastern Cambodia. Acta Trop 2004; 92(1): 1–6

[19] Asih PB, Marantina SS, Nababan R, Lobo NF, Rozi IE, Sumarto W, Dewi RM, Tuti S, Taufik AS, Mulyanto, Sauerwein RW, Syafruddin D. Distribution of Plasmodium vivax pvdhfr and pvdhps alleles and their association with sulfadoxine-pyrimethamine treatment outcomes in Indonesia. Malar J 2015; 14(1): 365

[20] Joy S, Ghosh SK, Achur RN, Gowda DC, Surolia N. Presence of novel triple mutations in the pvdhfr from Plasmodium vivax in Mangaluru city area in the southwestern coastal region of India. Malar J 2018; 17(1): 167

[21] Rakmark K, Awab GR, Duanguppama J, Boonyuen U, Dondorp AM, Imwong M. Polymorphisms in Plasmodium vivax antifolate resistance markers in Afghanistan between 2007 and 2017. Malar J 2020; 19(1): 251

[22] Barnadas C, Tichit M, Bouchier C, Ratsimbasoa A, Randrianasolo L, Raherinjafy R, Jahevitra M, Picot S, Ménard D. Plasmodium vivax dhfr and dhps mutations in isolates from Madagascar and therapeutic response to sulphadoxine-pyrimethamine. Malar J 2008; 7(1): 35

[23] Barnadas C, Timinao L, Javati S, Iga J, Malau E, Koepfli C, Robinson LJ, Senn N, Kiniboro B, Rare L, Reeder JC, Siba PM, Zimmerman PA, Karunajeewa H, Davis TM, Mueller I. Significant geographical differences in prevalence of mutations associated with Plasmodium falciparum and Plasmodium vivax drug resistance in two regions from Papua New Guinea. Malar J 2015; 14(1): 399

[24] Snounou G, Viriyakosol S, Zhu XP, Jarra W, Pinheiro L, do Rosario VE, Thaithong S, Brown KN. High sensitivity of detection of human malaria parasites by the use of nested polymerase chain reaction. Mol Biochem Parasitol 1993; 61(2): 315–320

[25] Price AL, Patterson NJ, Plenge RM, Weinblatt ME, Shadick NA, Reich D. Principal components analysis corrects for stratification in genome-wide association studies. Nat Genet 2006; 38(8): 904–909

[26] Kremsner PG, Krishna S. Antimalarial combinations. Lancet 2004; 364(9430): 285–294

[27] Miller KD, Lobel HO, Pappaioanou M, Patchen LC, Churchill FC. Failures of combined chloroquine and Fansidar prophylaxis in American travelers to East Africa. J Infect Dis 1986; 154(4): 689–691

[28] Plowe CV, Cortese JF, Djimde A, Nwanyanwu OC, Watkins WM, Winstanley PA, Estrada-Franco JG, Mollinedo RE, Avila JC, Cespedes JL, Carter D, Doumbo OK. Mutations in Plasmodium falciparum dihydrofolate reductase and dihydropteroate synthase and epidemiologic patterns of pyrimethamine-sulfadoxine use and resistance. J Infect Dis 1997; 176(6): 1590–1596

[29] Hastings MD, Porter KM, Maguire JD, Susanti I, Kania W, Bangs MJ, Sibley CH, Baird JK. Dihydrofolate reductase mutations in Plasmodium vivax from Indonesia and therapeutic response to sulfadoxine plus pyrimethamine. J Infect Dis 2004; 189(4): 744–750

[30] World Health Organization. Methods for the surveillance of antimalarial drug efficacy. Geneva: WHO, 2009

[31] Shaukat A, Ali Q, Connelley T, Khan MAU, Saleem MA, Evans M, Rashid I, Sargison ND, Chaudhry U. Selective sweep and phylogenetic models for the emergence and spread of pyrimethamine resistance mutations in Plasmodium vivax. Infect Genet Evol 2019; 68:221–230

[32] Leartsakulpanich U, Imwong M, Pukrittayakamee S, White NJ, Snounou G, Sirawaraporn W, Yuthavong Y. Molecular characterization of dihydrofolate reductase in relation to antifolate resistance in Plasmodium vivax. Mol Biochem Parasitol 2002; 119(1): 63–73

[33] Na BK, Lee HW, Moon SU, In TS, Lin K, Maung M, Chung GT, Lee JK, Kim TS, Kong Y. Genetic variations of the dihydrofolate reductase gene of Plasmodium vivax in Mandalay Division, Myanmar. Parasitol Res 2005; 96(5): 321–325

[34] Zhou Z. Malaria Control and Research in China. Beijing: People’s Medical Publishing House, 1991

[35] Yaqoob A, Khattak AA, Nadeem MF, Fatima H, Mbambo G, Ouattara A, Adams M, Zeeshan N, Takala-Harrison S. Prevalence of molecular markers of sulfadoxine-pyrimethamine and artemisinin resistance in Plasmodium falciparum from Pakistan. Malar J 2018; 17(1): 471

[36] de Pécoulas PE, Tahar R, Ouatas T, Mazabraud A, Basco LK. Sequence variations in the Plasmodium vivax dihydrofolate reductase-thymidylate synthase gene and their relationship with pyrimethamine resistance. Mol Biochem Parasitol 1998; 92(2): 265–273

[37] Lu F, Lim CS, Nam DH, Kim K, Lin K, Kim TS, Lee HW, Chen JH, Wang Y, Sattabongkot J, Han ET. Mutations in the antifolate-resistance-associated genes dihydrofolate reductase and dihydropteroate synthase in Plasmodium vivax isolates from malaria-endemic countries. Am J Trop Med Hyg 2010; 83(3): 474–479

[38] Korsinczky M, Fischer K, Chen N, Baker J, Rieckmann K, Cheng Q. Sulfadoxine resistance in Plasmodium vivax is associated with a specific amino acid in dihydropteroate synthase at the putative sulfadoxine-binding site. Antimicrob Agents Chemother 2004; 48(6): 2214–2222

[39] Miao M, Yang Z, Cui L, Ahlum J, Huang Y, Cui L. Different allele prevalence in the dihydrofolate reductase and dihydropteroate synthase genes in Plasmodium vivax populations from China. Am J Trop Med Hyg 2010; 83(6): 1206–1211

[40] Shang LY, Xue CG, Su SZ. Evaluation of the effect of 40 years anti-malaria measure in Henan Province. Chin J Parasitol Parasit Dis (Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi) 2000; 18(3): 189 (in Chinese)

[41] Liu XZ, Xu BL. Malaria situation and evaluation on the control effect in Henan Province during 1990−2005. Chin J Parasitol Parasit Dis (Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi) 2006; 24(3): 226–229(in Chinese) PMID:17094630

[42] Yang HL. Retrospect and prospect of application of antimalarial drugs in Yunnan Province. J Practical Parasitic Dis 1999; 7(4): 174–176

[43] Hawkins VN, Joshi H, Rungsihirunrat K, Na-Bangchang K, Sibley CH. Antifolates can have a role in the treatment of Plasmodium vivax. Trends Parasitol 2007; 23(5): 213–222

[44] Kyabayinze D, Cattamanchi A, Kamya MR, Rosenthal PJ, Dorsey G. Validation of a simplified method for using molecular markers to predict sulfadoxine-pyrimethamine treatment failure in African children with falciparum malaria. Am J Trop Med Hyg 2003; 69(3): 247–252

[45] Triglia T, Cowman AF. Primary structure and expression of the dihydropteroate synthetase gene of Plasmodium falciparum. Proc Natl Acad Sci USA 1994; 91(15): 7149–7153

[46] Brashear AM, Huckaby AC, Fan Q, Dillard LJ, Hu Y, Li Y, Zhao Y, Wang Z, Cao Y, Miao J, Guler JL, Cui L. New Plasmodium vivax genomes from the China−Myanmar border. Front Microbiol 2020; 11: 1930

[47] Liu Y, Auburn S, Cao J, Trimarsanto H, Zhou H, Gray KA, Clark TG, Price RN, Cheng Q, Huang R, Gao Q. Genetic diversity and population structure of Plasmodium vivax in Central China. Malar J 2014; 13(1): 262

[48] Li YC, Wang GZ, Meng F, Zeng W, He CH, Hu XM, Wang SQ. Genetic diversity of Plasmodium vivax population before elimination of malaria in Hainan Province, China. Malar J 2015; 14(1): 78

[49] Huang B, Huang S, Su XZ, Guo H, Xu Y, Xu F, Hu X, Yang Y, Wang S, Lu F. Genetic diversity of Plasmodium vivax population in Anhui Province of China. Malar J 2014; 13(1): 13

[50] Huang F, Zhou S, Zhang S, Zhang H, Li W. Meteorological factors-based spatio-temporal mapping and predicting malaria in central China. Am J Trop Med Hyg 2011; 85(3): 560–567

[51] Ding S, Ye R, Zhang D, Sun X, Zhou H, McCutchan TF, Pan W. Anti-folate combination therapies and their effect on the development of drug resistance in Plasmodium vivax. Sci Rep 2013; 3(1): 1008

[52] Pan JY, Zhou SS, Zheng X, Huang F, Wang DQ, Shen YZ, Su YP, Zhou GC, Liu F, Jiang JJ. Vector capacity of Anopheles sinensis in malaria outbreak areas of central China. Parasit Vectors 2012; 5(1): 136

[53] World Health Organization. Artemisinin resistance and artemisinin-based combination therapy efficacy. Geneva: WHO, 2019

Acknowledgements

We thank staff members of the local CDCs or hospitals for collecting the samples and the participants who provided blood samples. This study was supported by the Natural Science Foundation of Shanghai (No. 18ZR1443400), the Fifth Round of Three-year Public Health Action Plan of Shanghai (No. GWV-10.1-XK13), and the National Important Scientific & Technological Project (No. 2018ZX10101002-002).

Compliance with ethics guidelines

Fang Huang, Yanwen Cui, He Yan, Hui Liu, Xiangrui Guo, Guangze Wang, Shuisen Zhou, and Zhigui Xia declare that they have no conflicts of interest. This study was approved by the Ethical Review Committee of National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients.

Electronic Supplementary Material

Supplementary material is available in the online version of this article at https://doi.org/10.1007/s11684-021-0894-x and is accessible for authorized users.

RIGHTS & PERMISSIONS

2022 Higher Education Press