Molecular Epidemiology of Plasmodium falciparum Malaria Outbreak, Tumbes, Peru, 2010–2012 - Volume 21, Number 5—May 2015 - Emerging Infectious Disease journal - CDC

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Molecular Epidemiology of Plasmodium falciparum Malaria Outbreak, Tumbes, Peru, 2010–2012 - Volume 21, Number 5—May 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 5—May 2015

Research

Molecular Epidemiology of Plasmodium falciparum Malaria Outbreak, Tumbes, Peru, 2010–2012

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• Materials and Methods
• Results
• Discussion
• Suggested Citation

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• Figure 2

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• Table 2

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G. Christian Baldeviano , Sheila Akinyi Okoth, Nancy Arrospide, Rommell V. Gonzalez, Juan F. Sánchez, Silvia Macedo, Silvia Conde, L. Lorena Tapia, Carola Salas, Dionicia Gamboa, Yeni Herrera, Kimberly A. Edgel, Venkatachalam Udhayakumar, and Andrés G. Lescano

Author affiliations: US Naval Medical Research Unit No. 6, Callao, Peru (G.C. Baldeviano, J.F. Sánchez, S. Macedo, L.L. Tapia, C. Salas, K.A. Edgel, A.G. Lescano); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (S. Akinyi Okoth, V. Udhayakumar); Instituto Nacional de Salud del Peru, Lima, Peru (N. Arrospide); Direccion Regional de Salud de Tumbes, Tumbes, Peru (R.V. Gonzalez, S. Conde); Universidad Peruana Cayetano Heredia, Lima (D. Gamboa); Ministry of Health of Peru, Lima (Y. Herrera)

Suggested citation for this article

Abstract

During 2010–2012, an outbreak of 210 cases of malaria occurred in Tumbes, in the northern coast of Peru, where no Plasmodium falciparum malaria case had been reported since 2006. To identify the source of the parasite causing this outbreak, we conducted a molecular epidemiology investigation. Microsatellite typing showed an identical genotype in all 54 available isolates. This genotype was also identical to that of parasites isolated in 2010 in the Loreto region of the Peruvian Amazon and closely related to clonet B, a parasite lineage previously reported in the Amazon during 1998–2000. These findings are consistent with travel history of index case-patients. DNA sequencing revealed mutations in the Pfdhfr, Pfdhps, Pfcrt, and Pfmdr1loci, which are strongly associated with resistance to chloroquine and sulfadoxine/pyrimethamine, and deletion of the Pfhrp2 gene. These results highlight the need for timely molecular epidemiology investigations to trace the parasite source during malaria reintroduction events.

During the past decade, remarkable progress in malaria control has been achieved globally (1). As low-risk areas progress toward the preelimination phase of malaria elimination (http://www.who.int/malaria/areas/elimination/overview/en/), new challenges are posed by risk for reintroduction of parasites into areas where malaria transmission was interrupted (2). Human movement from malaria-endemic regions could facilitate outbreaks in areas where malaria had been eliminated (2,3). Molecular epidemiology tools have been used to investigate the sources of malaria reintroduction (4,5). Use of these tools enables rapid characterization of potentially pathogenic or multidrug-resistant strains before they become adapted and expand to other non–malaria-endemic areas where anopheline vectors are present (6–9).

In Peru, malaria reemerged in the 1990s and the number of cases peaked at ≈160,000 cases in 1998 (10). Most reported cases had occurred in the Amazon Basin (Loreto region) and areas in the northern Pacific coast of Peru, including the Tumbes and Piura regions. In vivo efficacy studies conducted during 1998–2000 revealed different patterns of drug resistance between parasites in the Amazon region and coastal areas (11,12). Although parasites from the eastern Amazon region were resistant to chloroquine and sulfadoxine/pyrimethamine, parasites from the northern Pacific coast were resistant to chloroquine but remained sensitive to sulfadoxine/pyrimethamine (11–13). In 2001, artesunate/mefloquine combination therapy was introduced in the Peruvian Amazon while artesunate–sulfadoxine/pyrimethamine remained in use in the northern Pacific coastal region (12).

After 2005, changes in drug policy and increased vector control efforts in Peru led to a drastic reduction in the number of malaria cases in the country. A major accomplishment was the interruption of Plasmodium falciparum transmission in the northern Pacific coast; no autochthonous malaria case has been reported since 2006. However, in October of 2010, the Regional Health Directorate in Tumbes received reports of 2 cases of P. falciparum malaria. An outbreak investigation confirmed the P. falciparum malaria epidemic in Tumbes. This outbreak continued to spread through 2012, when the last case of P. falciparum malaria was reported. Epidemiology investigations identified 2 index case-patients among military personnel stationed in Tumbes; surveillance activities conducted during the outbreak investigation suggested that these patients potentially acquired P. falciparum infection while in the Peruvian Amazon. We therefore hypothesized that a detailed genetic characterization of the parasite populations isolated during this outbreak might provide a better understanding of the source and main biological features of the parasite responsible for the reintroduction of malaria into Tumbes.

Previous genetic analyses of P. falciparum strains collected at the peak of the malaria epidemic, 1999–2000, revealed at least 5 distinct clonal lineages (clonets A–E), as defined by genotyping of 7 neutral microsatellite loci (14). These clonets, which were distributed in different areas of Peru, exhibited distinct patterns of mutations based on sequencing of the Pfcrt, Pfmdr1, Pfdhps, and Pfdhfr genes (14). Considering these historical data, we tested the following hypotheses. First, if the P. falciparum outbreak in Tumbes was caused by bottlenecked parasites from the coastal region, the parasites causing this outbreak would be genetically similar or closely related to clonet E, which was the only lineage found in the northern Pacific coast during 1999–2000. Second, if the parasite was introduced from the Peruvian Amazon, then the parasites causing this outbreak would be related to clonets A, B, C, or D. Third, if these parasites were introduced from outside Peru, they may have different molecular signatures.

Dr. Baldeviano is the head of the Immunology and Vaccine Development Unit, Department of Parasitology, NAMRU-6. His research focuses on the use of genetic, immunologic, and high-throughput tools for the control and prevention of malaria.

Acknowledgments

We are grateful to all the personnel of the Ministry of Health in Tumbes and Lima who were involved in the response to the outbreak and who assisted with collection of patient information and samples. We also thank Jaime Chang and Guillermo Gonzalvez for their guidance and contributions to the control of the outbreak, and we acknowledge the assistance provided by the Center for Global Health of the Universidad Peruana Cayetano Heredia, which provided valuable logistical support to this study.

This work was funded by the US Department of Defense Armed Forces Health Surveillance Center, Global Emerging Infectious Systems Division, through the Malaria Pillar Sustainment grant awarded to A.G.L. In addition, this investigation was partly supported by the Amazon Malaria Initiative, which is financially supported by the US Agency for International Development. S.A. was supported by the American Society of Microbiology/CDC Postdoctoral Fellowship Program. The participation of A.G.L. in this investigation was sponsored by training grant NIH/FIC 2D43 TW007393 awarded to NAMRU-6 by the Fogarty International Center of the US National Institutes of Health.

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Figures

• Figure 1. Peru, showing the department of Tumbes (black shading), the city of Iquitos, and the Requena district located in the Loreto region of the Peruvian Amazon (A) and the 13...
• Figure 2. Temporal distribution of cases of falciparum malaria reported to the Tumbes Regional Health Directorate, Peru, October 2010–June 2012. Black bar sections indicate number of cases with samples available for...

Tables

• Table 1. Genetic lineage based on 7 neutral microsatellite markers of representative Plasmodium falciparum isolates from malaria outbreak in Tumbes and Amazon Region, Peru, 2010–2012
• Table 2. Drug resistant allele haplotypes of representative Plasmodium falciparum isolates from the Tumbes outbreak, clonets A–E, and isolates from the Amazon region, Peru, 2010–2012

Suggested citation for this article: Baldeviano GC, Akinyi Okoth S, Arrospide N, Gonzalez RV, Sánchez JF, Macedo S, et al. Molecular epidemiology of malaria outbreak, Tumbes, Peru, 2010–2012. Emerg Infect Dis. 2015 May [date cited]. http://dx.doi.org/10.3201/eid2105.141427

DOI: 10.3201/eid2105.141427