Skip to main content
SpringerLink
Log in

Prevalence of antifolate drug resistance markers in Plasmodium vivax in China

  • Research Article
  • Published:
Frontiers of Medicine Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

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

    Article  PubMed  PubMed Central  Google Scholar 

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

    Book  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Google Scholar 

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

    Google Scholar 

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

    Book  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

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

    Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Shang LY, Xue CG, Su SZ. Evaluation of the effect of 40 years antimalaria 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)

    CAS  Google Scholar 

  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)

    Google Scholar 

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

    Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  53. World Health Organization. Artemisinin resistance and artemisininbased combination therapy efficacy. Geneva: WHO, 2019

    Google Scholar 

Download references

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).

Author information

Authors and Affiliations

  1. National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Chinese Center for Tropical Diseases Research, WHO Collaborating Center for Tropical Diseases, National Centre for International Research on Tropical Diseases, NHC Key Laboratory of Parasite and Vector Biology (National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention), Shanghai, 200025, China

    Fang Huang, Yanwen Cui, He Yan, Shuisen Zhou & Zhigui Xia

  2. Yunnan Institute of Parasitic Diseases, Puer, 665000, China

    Hui Liu

  3. Yingjiang County for Disease Control and Prevention, Yingjiang, 679300, China

    Xiangrui Guo

  4. Hainan Center for Disease Control & Prevention, Haikou, 570203, China

    Guangze Wang

Authors
  1. Fang Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yanwen Cui
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. He Yan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hui Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Xiangrui Guo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Guangze Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shuisen Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Zhigui Xia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Fang Huang.

Additional information

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

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, F., Cui, Y., Yan, H. et al. Prevalence of antifolate drug resistance markers in Plasmodium vivax in China. Front. Med. 16, 83–92 (2022). https://doi.org/10.1007/s11684-021-0894-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11684-021-0894-x

Keywords

Search

Navigation