Priyanto Sismadi

Randomized, Parallel Placebo-Controlled Trial of Primaquine for Malaria Prophylaxis in Papua, Indonesia

Malaria causes illness or death in unprotected travelers. Primaquine prevents malaria by attacking liver-stage parasites, a property distinguishing it from most chemoprophylactics and obviating 4-week postexposure dosing. A daily adult regimen of 30 mg primaquine prevented malaria caused by Plasmodium falciparum and P. vivax for 20 weeks in 95 of 97 glucose-6-phosphate dehydrogenase (G6PD)-normal Javanese transmigrants in Papua, Indonesia. In comparison, 37 of 149 subjects taking placebo in a parallel trial became parasitemic. The protective efficacy of primaquine against malaria was 93% (95% confidence interval [CI] 71%-98%); against P. falciparum it was 88% (95% CI 48%-97%), and >92% for P. vivax (95% CI >37%-99%). Primaquine was as well tolerated as placebo. Mild methemoglobinemia (mean of 3.4%) returned to normal within 2 weeks. Blood chemistry and hematological parameters revealed no evidence of toxicity. Good safety, tolerance, and efficacy, along with key advantages in dosing requirements, make primaquine an excellent drug for preventing malaria in nonpregnant, G6PD-normal travelers.

Chloroquine-resistant Plasmodium malariae in south Sumatra, Indonesia

Oral chloroquine is the treatment of choice for uncomplicated Plasmodium malariae infections worldwide. We did a prospective 28-day in-vivo assessment of the efficacy of chloroquine for treatment of P malariae on Legundi Island in Lampung Bay, Sumatra, Indonesia. Of 28 patients, one had recurrent parasitaemia on day 28, and two had persistent parasitaemia to day 8. Whole-blood chloroquine and desethylchloroquine concentrations were at ordinarily effective levels (> or = 100 microg/L) on day 8 in both cases of persistent parasitaemia. These findings suggest that clinical resistance to chloroquine by P malariae occurs in the Indonesian archipelago of southeast Asia.

Randomized, Placebo-Controlled Trial of Atovaquone/Proguanil for the Prevention of Plasmodium falciparum or Plasmodium vivax Malaria among Migrants to Papua, Indonesia

The increasing prevalence of resistance to antimalarial drugs reduces options for malaria prophylaxis. Atovaquone/proguanil (Malarone; GlaxoSmithKline) has been >95% effective in preventing Plasmodium falciparum malaria in lifelong residents of areas of holoendemicity, but data from persons without clinical immunity or who are at risk for Plasmodium vivax malaria have not been described. We conducted a randomized, double-blinded study involving 297 people from areas of nonendemicity in Indonesia who migrated to Papua (where malaria is endemic) < or =26 months before the study period. Subjects received prophylaxis with 1 Malarone tablet (250 mg of atovaquone and 100 mg of proguanil hydrochloride; n=148) or placebo (n=149) per day for 20 weeks. Hematologic and clinical chemistry values did not change significantly. The protective efficacy of atovaquone/proguanil was 84% (95% confidence interval [CI], 44%-95%) for P. vivax malaria, 96% (95% CI, 72%-99%) for P. falciparum malaria, and 93% (95% CI, 77%-98%) overall. Atovaquone/proguanil was well tolerated, safe, and effective for the prevention of drug-resistant P. vivax and P. falciparum malaria in individuals without prior malaria exposure who migrated to Papua, Indonesia.

Production and validation of durable, high quality standardized malaria microscopy slides for teaching, testing and quality assurance during an era of declining diagnostic proficiency

BackgroundSets of Giemsa-stained, blood smear slides with systematically verified composite diagnoses would contribute substantially to development of externally validated quality assurance systems for the microscopic diagnosis of malaria.Methodswhole blood from Plasmodium-positive donors in Cambodia and Indonesia and individuals with no history of risk for malaria was collected. Using standard operating procedures, technicians prepared Giemsa-stained thick and thin smears from each donor. One slide from each of the first 35 donations was distributed to each of 28 individuals acknowledged by reputation as having expertise in the microscopic diagnosis of malaria. These reference readers recorded presence or absence of Plasmodium species and parasite density. A composite diagnosis for each donation was determined based on microscopic findings and species-specific small subunit ribosomal RNA (ssrRNA) DNA polymerase chain reaction (PCR) amplification.ResultsMore than 12, 000 slides were generated from 124 donations. Reference readers correctly identified presence of parasites on 85% of slides with densities <100 parasites/μl, which improved to 100% for densities >350 parasites/μl. Percentages of agreement with composite diagnoses were highest for Plasmodium falciparum (99%), followed by Plasmodium vivax (86%).ConclusionHerein, a standardized method for producing large numbers of consistently high quality, durable Giemsa-stained blood smears and validating composite diagnoses for the purpose of creating a malaria slide repository in support of initiatives to improve training and competency assessment amidst a background of variability in diagnosis is described.

Atovaquone/Proguanil Therapy for Plasmodium falciparum and Plasmodium vivax Malaria in Indonesians Who Lack Clinical Immunity

Thirty-eight of 295 subjects participating in a randomized, double-blind, placebo-controlled trial of the efficacy of daily administration of atovaquone/proguanil for malaria prevention developed malaria at some time during the 20-week prophylaxis period. These subjects (3 atovaquone/proguanil recipients and 35 placebo recipients) were treated with 4 tablets of atovaquone/proguanil per day for 3 days. Atovaquone/proguanil provided safe, well-tolerated, and effective therapy for uncomplicated malaria in nonimmune Indonesians.

The T76 mutation in the pfcrt gene of Plasmodium falciparum and clinical chloroquine resistance phenotypes in Papua, Indonesia

The T76 mutation in the pfcrt gene has been linked to chloroquine (CQ) resistance in Plasmodium falciparum. PCR-based analysis of pfcrt alleles was performed on pre-treatment samples from 107 individuals who had P. falciparum infections and lived in Papua, Indonesia. The results of a 28-day, in-vivo test revealed clinical resistance to CQ in 79 (74%) of the samples. The crude sensitivity of the pfcrt T76 assay for detecting the CQ-resistant infections in the samples was 96% and the crude specificity 52%. Discordance between pfcrt genotype and in-vivo phenotype was analysed either by genotyping of the merozoite surface protein-2 (to distinguish re-infection from recrudescence) or by amplification of the P. falciparum-specific small-subunit ribosomal RNA (ssrRNA) gene, using nested PCR (to detect any sub-patent but resistant parasites in infections misclassified as sensitive by the in-vivo test). When adjusting for the results of these analyses, the sensitivity and specificity of the pfcrt T76 assay for detecting the CQ-resistant infections became 93% and 82%, respectively. Overall, the present results indicate that the pfcrt T76 assay may be used to forecast therapeutic failure caused by CQ resistance. Validation requires exploration of the phenotype classifications based on the results of in-vivo tests, using genetic analyses that distinguish re-infection from recrudescence and detect microscopically subpatent parasitaemias.

Remotely-sensed land use patterns and the presence of Anopheles larvae (Diptera: Culicidae) in Sukabumi, West Java, Indonesia

ABSTRACT Land use patterns and the occurrence of Anopheles species larvae were studied in Sukabumi District, West Java, Indonesia, from October 2004 to September 2005. Two land use maps derived using remote sensing were used. One map derived from Quickbird satellite images of 150 km2 of the Simpenan and Ciemas subdistricts (106° 27′53″–106° 38′38″ E and 6° 59′59″–7° 8′46″ S) in Sukabumi and one using ASTER images covering 4,000 km2 of Sukabumi District from 106° 22′15″–107° 4′1″ E and 6° 42′50″–7° 26′13″ S. There was a total of 11 Anopheles spp. collected from 209 sampling locations in the area covered by the Quickbird image and a total of 15 Anopheles spp. collected from 1,600 sampling locations in the area covered by the ASTER map. For the area covered by the land use maps, ten species were found to have statistically positive relationships between land use class and species presence: Anopheles aconitus, An. annularis, An. barbirostris. An. flavirostris, An. insulaeflorum, An. kochi, An. maculatus, An. subpictus, An. sundaicus, and An. vagus. Quickbird and ASTER satellite images both produced land maps that were adequate for predicting species presence in an area. The land use classes associated with malaria vector breeding were rice paddy (An. aconitus, An. subpictus), plantation located near or adjacent to human settlements (An. maculatus), bush/shrub (An. aconitus, An. maculatus, An. sundaicus), bare land, and water body land use on the coast located ≤ 250 m of the beach (An. sundaicus). Understanding the associations of habitat and species in one area, predictions of species presence or absence can be made prior to a ground survey allowing for accurate vector survey and control planning.

Chloroquine or sulfadoxine-pyrimethamine for the treatment of uncomplicated, Plasmodium falciparum malaria during an epidemic in Central Java, Indonesia.

Abstract A recent malaria epidemic in the Menoreh Hills of Central Java has increased concern about the re-emergence of endemic malaria on Java, which threatens the islands 120 million residents. A 28-day, in-vivo test of the efficacy of treatment of malaria with antimalarial drugs was conducted among 167 villagers in the Menoreh Hills. The treatments investigated, chloroquine (CQ) and sulfadoxine-pyrimethamine (SP), constitute, respectively, the first- and second-line treatments for uncomplicated malaria in Indonesia. The prevalence of malaria among 1389 residents screened prior to enrollment was 33%. Treatment outcomes were assessed by microscopical diagnoses, PCR-based confirmation of the diagnoses, measurement of the whole-blood concentrations of CQ and desethylchloroquine (DCQ), and identification of the Plasmodium falciparum genotypes. The 28-day cumulative incidences of therapeutic failure for CQ and SP were, respectively, 47% (N = 36) and 22% (N = 50) in the treatment of P. falciparum, and 18% (N = 77) and 67% (N = 6) in the treatment of P. vivax. Chloroquine was thus an ineffective therapy for P. falciparum malaria, and the presence of CQ-resistant P. vivax and SP-resistant P. falciparum will further compromise efforts to control resurgent malaria on Java.

Combined chloroquine, sulfadoxine/pyrimethamine and primaquine against Plasmodium falciparum in Central Java, Indonesia

BackgroundChloroquine (CQ) or sulfadoxine-pyrimethamine (SP) monotherapy for Plasmodium falciparum often leads to therapeutic failure in Indonesia. Combining CQ with other drugs, like SP, may provide an affordable, available and effective option where artemisinin-combined therapies (ACT) are not licensed or are unavailable.MethodsThis study compared CQ (n = 29 subjects) versus CQ + SP (with or without primaquine; n = 88) for clinical and parasitological cure of uncomplicated falciparum malaria in the Menoreh Hills region of southern Central Java, Indonesia. Gametocyte clearance rates were measured with (n = 56 subjects) and without (n = 61) a single 45 mg dose of primaquine (PQ).ResultsAfter 28 days, 58% of subjects receiving CQ had cleared parasitaemia and remained aparasitaemic, compared to 94% receiving CQ combined with SP (p < 0.001). Msp-2 genotyping permitted reinfection-adjusted cure rates for CQ and CQ combined with SP, 70% and 99%, respectively (p = 0.0006).ConclusionPrimaquine exerted no apparent affect on cure of asexual stage parasitaemia, but clearly accelerated clearance of gametocytes. CQ combined with SP was safe and well-tolerated with superior efficacy over CQ for P. falciparum parasitaemia in this study.

Environmental Factors Associated with Spatial and Temporal Distribution of Anopheles (Diptera: Culicidae) Larvae in Sukabumi, West Java, Indonesia

Abstract A 12-mo ecological study of the spatial-temporal distribution of immature stages of Anopheles species was conducted in Sukabumi District, West Java, Indonesia. The study characterized 1,600 sites from a contiguous coastal and hill zone (0–800-m elevation) of which 64% contained Anopheles larvae. Principal component and multiple logistic regression analyses identified ecological parameters associated with presence of nine [Anopheles aconitus Doenitz, Anopheles annularis Van de Wulp, Anopheles barbirostris Van der Wulp, Anopheles flavirostris (Ludlow), Anopheles insulaeflorum (Swellengrebel and Swellengrebel de Graaf), Anopheles kochi Doenitz, Anopheles maculatus Theobald, Anopheles sundaicus (Rodenwaldt), and Anopheles vagus Doenitz] of 15 Anopheles species collected. Combined data for all nine species showed increased Anopheles presence associated with wet season periods and higher elevation habitats exhibiting reduced tree canopy coverage, higher water temperatures, and shallower water depths. Habitat variables measured included topography (elevation), water conditions (temperature, pH, salinity depth, and velocity), habitat characteristics (substrate and canopy cover), density and type of aquatic vegetation coverage (riparian, floating, and emergent), and distance from nearest human habitation. Significant relationships were found for nine species when using all habitats in the analysis. Habitat characteristics for three species were refined. An. aconitus and An. barbirostris were associated with higher elevation rice, Oryza savita L., paddies with relatively shallow water depths, higher water temperatures, higher acidity and salinity concentrations, and a greater average distance from human habitation. An. vagus presence in rice paddies was associated with lower elevation fields, deeper and cooler water, less acidic and saline conditions, and habitats closer to human dwellings. Overall, the distribution of Anopheles species in Sukabumi was found to be nonrandom and predictable on the basis of habitat characteristics.