In vivo efficacy of artesunate-amodiaquine and artemether-lumefantrine for the treatment of uncomplicated falciparum malaria: an open-randomized, non-inferiority clinical trial in South Kivu, Democratic Republic of Congo

Abstract

Background: Between 2009 and 2012, malaria cases diagnosed in a Médecins sans Frontières programme have increased fivefold in Baraka, South Kivu, Democratic Republic of the Congo (DRC). The cause of this increase is not known. An in vivo drug efficacy trial was conducted to determine whether increased treatment failure rates may have contributed to the apparent increase in malaria diagnoses.

Methods: In an open-randomized non-inferiority trial, the efficacy of artesunate-amodiaquine (ASAQ) was compared to artemether-lumefantrine (AL) for the treatment of uncomplicated falciparum malaria in 288 children aged 6-59 months. Included children had directly supervised treatment and were then followed for 42 days with weekly clinical and parasitological evaluations. The blood samples of children found to have recurring parasitaemia within 42 days were checked by PCR to confirm whether or not this was due to reinfection or recrudescence (i.e. treatment failure).

Results: Out of 873 children screened, 585 (67 %) were excluded and 288 children were randomized to either ASAQ or AL. At day 42 of follow up, the treatment efficacy of ASAQ was 78 % before and 95 % after PCR correction for re-infections. In the AL-arm, treatment efficacy was 84 % before and 99.0 % after PCR correction. Treatment efficacy after PCR correction was within the margin of non-inferiority as set for this study. Fewer children in the AL arm reported adverse reactions.

Conclusions: ASAQ is still effective as a treatment for uncomplicated malaria in Baraka, South Kivu, DRC. In this region, AL may have higher efficacy but additional trials are required to draw this conclusion with confidence. The high re-infection rate in South-Kivu indicates intense malaria transmission. Trial registration NCT02741024.

Keywords: Artemether–lumefantrine; Artesunate–amodiaquine; Child; DR Congo; DRC; Plasmodium falciparum; Treatment efficacy; Uncomplicated malaria.

Figures

Fig. 1

Map of the Democratic Republic of Congo

Fig. 2

Confirmed malaria cases in Baraka project 2009–2012, DRC

Fig. 3

Trial profile efficacy study ASAQ–AL, Baraka, DRC

Fig. 4

Kaplan–Meier survival estimates PCR-unadjusted. Treatment efficacy for ASAQ and AL was 85.3 and 92.1 % at day 28 (p = 0.0933), and 77.7 and 84.5 % at day 42 (p = 0.1605), respectively

Fig. 5

Kaplan–Meier survival estimates PCR-adjusted. Treatment efficacy for ASAQ and AL was 96.6 and 100 % at day 28 (p = 0.0406), and 94.7 and 99.0 % at day 42 (p = 0.0496), respectively