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• W1897137839 abstract "We appreciate the comments on our recent Article1Price RN von Seidlein L Valecha N Nosten F Baird JK White NJ Global extent of chloroquine-resistant Plasmodium vivax: a systematic review and meta-analysis.Lancet Infect Dis. 2014; 14: 982-991Summary Full Text Full Text PDF PubMed Scopus (263) Google Scholar that reports on the global extent of antimalarial drug resistance in Plasmodium vivax. Wei Wang and colleagues raise concerns that our review ignores relevant literature documenting P vivax chloroquine resistance in China. We constrained our analysis to articles published in English or from which data could be readily extracted, and hence did not identify the three reports in Chinese mentioned by Wang and colleagues. Two of these are case reports of possible chloroquine resistance, without confirmation of adequate blood concentrations. Wei and colleagues2Wei T Li GL Huang YS Dai CF Chen GL Chloroquine-resistant malaria: a report of 47 cases.Peop Mil Surg. 2000; 43 (in Chinese).: 158-159Google Scholar report 21 patients who were not cured with a combination of chloroquine plus primaquine, several of whom had high-grade early treatment failure. The absolute risk of these events cannot be gauged because the total number of patients treated is not stated. We would be delighted to review the studies in more detail if the original articles can be provided. Our review included two clinical trials done in China, neither of which reported any patients not responding to antimalarial treatment, although in both studies the early administration of primaquine might have masked the presence of low-grade chloroquine resistance. There have been two relevant articles since our review was published. A study by Liu and colleagues3Liu H Yang HL Tang LH et al.Monitoring Plasmodium vivax chloroquine sensitivity along China–Myanmar border of Yunnan Province, China during 2008–2013.Malar J. 2014; 13: 364Crossref PubMed Scopus (24) Google Scholar from the China–Myanmar border of Yunnan province, reported nine (1·5%) of 603 patients with late treatment failure. On the Myanmar side of the border, Yuan and colleagues4Yuan L Wang Y Parker DM et al.Therapeutic responses of Plasmodium vivax malaria to chloroquine and primaquine treatment in northeastern Myanmar.Antimicrob Agents Chemother. 2015; 59: 1230-1235Crossref PubMed Scopus (39) Google Scholar report a study done in 2012 and 2013, in which ten (5·4%) of 401 patients did not respond to treatment. Although overall chloroquine efficacy was high in these studies, several patients had early high-grade treatment failure, and these occurred after chloroquine was given in combination with primaquine; the underlying efficacy of chloroquine monotherapy is likely to be substantially worse. There were no treatment failures in an unpublished study done in 2007 in the same region. These figures show the potential risk of emerging chloroquine resistance along the China–Myanmar border and emphasises the importance in maintaining vigilance for the spread of antimalarial drug resistance in this region. Nathan Brendish questions whether our primary outcome of chloroquine efficacy at day 28 is compatible with table 1, which lists studies of shorter duration. Our review also aimed to document the diversity of clinical trial design and analysis that has been applied to P vivax, and hence all relevant studies were tabulated. However, in the four studies with less than 28 days follow-up and a further three with no available data at day 28, the day 28 efficacy outcome was uncategorised. Data were extracted by one of the authors, but the entire dataset is provided in a supplementary file available online at the Worldwide Antimalarial Resistance Network,5Worldwide Antimalarial Resistance NetworkAntimalarial efficacy against P vivax.http://www.wwarn.org/tools-resources/literature-reviews/chloroquine-resistant-plasmodium-vivax-reviewDate: 2014Google Scholar in a form amenable to independent analysis and cross checking. The management of chloroquine-resistant P vivax has been discussed at length in a previous review6Douglas NM Anstey NM Angus BJ Nosten F Price RN Artemisinin combination therapy for vivax malaria.Lancet Infect Dis. 2010; 10: 405-416Summary Full Text Full Text PDF PubMed Scopus (187) Google Scholar and is presented comprehensively in the latest WHO antimalarial guidelines.7WHOGuidelines for the treatment of malaria. 3rd edn. World Health Organization, Geneva2015http://www.who.int/malaria/publications/atoz/9789241549127/en/Google Scholar RNP, KJB, NV, and NJW are members of the WHO steering committee for the Development of a Global Strategic Plan for Plasmodium vivax control and elimination. NJW is co-chairman of the WHO antimalarial treatment guidelines committee. RNP is a Wellcome Trust Senior Research Fellow in Clinical Science, NJW is a Wellcome Trust Principal Fellow, JKB is supported by a Wellcome Trust Project Grant B9RJIXO, and LvS is a member of the Asia Pacific Malaria Elimination Network. Global extent of chloroquine-resistant Plasmodium vivax: a systematic review and meta-analysisHeterogeneity of study design and analysis has confounded global surveillance of chloroquine-resistant P vivax, which is now present across most countries endemic for P vivax. Improved methods for monitoring of drug resistance are needed to inform antimalarial policy in these regions. Full-Text PDF Open AccessGlobal extent of chloroquine-resistant Plasmodium vivaxMalaria is a major public health problem in tropical regions, particularly in sub-Saharan Africa. Control still relies on chemotherapy. For decades, chloroquine has been the first-line drug for the treatment of malaria. After long-term extensive use, widespread resistance to chloroquine has been detected in malaria parasites, including Plasmodium falciparum and Plasmodium vivax. In a recent systematic review in The Lancet Infectious Diseases that involved 179 study sites in Asia, Africa, and South America, Ric Price and colleagues1 conclude that chloroquine resistance has spread across most countries endemic for P vivax. Full-Text PDF Global extent of chloroquine-resistant Plasmodium vivaxI wish to thank Ric Price and colleagues1 for highlighting the under-studied chloroquine resistance in Plasmodium vivax in their systematic review and meta-analysis. However, I would question their study inclusion criteria: the primary outcome was “the risk of recurrent P vivax parasitaemia at day 28” when table 1 lists four studies with follow-up periods of less than 27 days. I would also suggest that it seems a shame that two author-reviewers, independently, did not extract and analyse the studies and data for inclusion, as seems standard practice for good systematic reviews. Full-Text PDF" @default.
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• W1897137839 title "Global extent of chloroquine-resistant Plasmodium vivax – Authors' reply" @default.
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