Therapeutic efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium

falciparum malaria in Metehara, East-Central Ethiopia

By
Mahelet Tesfaye

A Thesis Submitted to Department of Microbial, Cellular and Molecular Biology, College of

Natural and Computational Sciences; Addis Ababa University
In Partial Fulfillment of the Requirements for the Degree of Master of Science in Infection
Biology

Supervisors: Prof. Hassen Mamo¹, Dr Ashenafi Assefa²

May 2022
Addis Ababa
Ethiopia
1
Department of Microbial, Cellular and Molecular Biology, College of Natural and Computational Sciences, Addis
Ababa University PO Box 1176, Addis Ababa, ET 2Ethiopian Public Health Institute, Addis Ababa, ET

Table of Contents
Abstract......................................................................................................................................................6

1
1. Introduction.......................................................................................................................................7

1.1 Background of the study...........................................................................................................7

1.2 Statement of the problem..........................................................................................................8

1.3 Objective.....................................................................................................................................8

General objective...................................................................................................................................8

1.4 Global Burden of Malaria.......................................................................................................10

3.1 Study design...................................................................................................................................19

3.3. Sample size...............................................................................................................................19

3.4. Timing and duration of study.................................................................................................20

3.5. Study Subjects, inclusion criteria, exclusion criteria............................................................20

3.5.1. Study Subjects..................................................................................................................20

3.5.2. Inclusion criteria..............................................................................................................20

3.5.3. Exclusion criteria.............................................................................................................20

3.6. Data collection and sampling technique.................................................................................21

3.6.1. Recruiting of study participants.........................................................................................21

3.6.2. Physical examination.......................................................................................................21

3.6.3. Laboratory examination..................................................................................................21

3.7. Drug administration................................................................................................................21

3.8. Data analysis............................................................................................................................21

3.9. Ethical Consideration..............................................................................................................22

4. Results..................................................................................................................................................23

4.1 Participants....................................................................................................................................23

4.2. Primary Endpoint.........................................................................................................................25

4.3. Secondary Endpoint.....................................................................................................................25

4.4. Advert events...............................................................................................................................26

4. Discussion.........................................................................................................................................29

5. Conclusion........................................................................................................................................31

6. Reference..........................................................................................................................................32

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List of tables

Table 1: Baseline characteristics of the study participants at Metehara Health Center, East-
Central Ethiopia, 2021.

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Table 2: Treatment outcomes based on Per Protocol analysis among patients treated with
artemether lumefantrine at Metehara Health Center.
Table 3: Probable adverse events at base line with their frequency in percent. December to
March 2020/2021.

List of Figures

Figure .1. Screening, enrollment, follow-up and treatment outcomes of P. falciparum malaria
patients in Metehara Health Center.

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Figure.2. Survival analysis of 28-day cure rate of P. falciparum for Artemether lumefantrine,
Metehara, December to March 2020/2021.

Figure.3. Mean body temperature on the first three follow-up days.

Figure.4. Gametocytes carriage on each follow-up days.

ABRRIVATIONS

ACPR-adequate clinical and parasitological response

AS-AQ-artesunate/amodiaquine
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AS-MQ-artesunate/mefloquine

ACT-artemisinin combination therapies

ART-artemisinin derivatives

CQ-chloroquine

DHA-PPQ-dihydroartemisinin-piperaquine

ETF-early treatment failure

EPHI-Ethiopian Public Health Institution

Glurp-glutamate rich protein

ITNs-insecticide-treated nets

IRS- indoor residual spraying

LCF-late clinical failure

LPF- late parasitological failure

MPR-malaria programme review

Msp1-merozoite surface protein 1

Msp2-merozoite surface protein 2

NMSP-national malaria strategic plan

P.F-plasmodium falciparum

Pfcrt P- falciparum chloroquine resistance transporter

Pfcytb-P. falciparum cytochrome B

Pfdhfr-P. falciparum dihydrofolate reductase

Pfdhps-P. falciparum dihydropteroate synthase

Pfmdr1-P. falciparum multidrug resistance protein 1

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Pfnhe-1-P. falciparum sodium–hydrogen exchanger gene

Pfk13- P. falciparum kelch13

P.V -plasmodium vivax

RSAs-ring-stage survival assays

SSA-sub-Saharan Africa

TES-therapeutic efficacy studies

WHO-world health organization

WBCs-white blood cells

Abstract
Monitoring and identification of drug-resistant P. falciparum strains is paramount for the fight
against malaria. Close surveillance of the emergence and distribution of ACT resistance is
recommended to guide policy decisions. The efficacy of national first- and second-line anti-

7
malarial treatments should be monitored at least once every 2 years, as recommended in the
WHO standard protocol. In Ethiopia, a three-day regime of AL (artemether 20mg and
lumefantrine 120mg in each tablet) and single dose primaquine (PQ) is the first-line anti-malarial
drug for the treatment of uncomplicated P. falciparum malaria since 2004. The objective of this
study was assessing the therapeutic efficacy of AL for the treatment of uncomplicated P.
falciparum malaria in Metehara, east-central Ethiopia. The study was conducted in Eastern
Shewa zone health department, Metehara town health center, Ethiopia. One-arm prospective
evaluation conducted on the clinical and parasitological responses to directly observed treatment
for uncomplicated P. falciparum malaria. Study end-points were divided into primary end-point
and secondary end-point. While the primary end-point was the day-28 adequate clinical and
parasitological response the additional end-points were clinical and parasitological evaluations
(parasite, fever and gametocyte clearance rate, incidence of drug adverse events). A total of 92
patients were enrolled and 73 had completed the 28-day follow-up period. The overall cure rate
was 98.8% with 95% confidence interval of 0.915± 0.998 without polymerase chain reaction
correction. The majority of research participants completely recovered from parasitemia and
fever on D3; the parasite clearance rate was high and clinical symptoms resolved quickly.
Gametocyte carriage was reduced from 8.4% on D0 to 1% on D3 and complete clearance was
achieved on D 7. There was no serious adverse event. In the study location, AL is effective for
treating uncomplicated P. falciparum malaria.

Key words: Artemether- Lumefantrine, P. falciparum, TES

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 1. Introduction
1.1 Background of the study
Malaria is a disease of the most vulnerable: the very young and the poor. Globally, there were an
estimated 229 million cases and 409,000 deaths of malaria in 2019 in 87 malaria-endemic
countries (WHO, 2020). In 2020, 1 year after the COVID-19 pandemic and service disruptions,
the estimated number of malaria cases rose to 241 million cases and 627,000 death, an additional
14 million cases and 218,000 death compared with 2019 (WHO, 2021b).WHO has launched the
Global Technical Strategy for Malaria 2016-2030 with the aim of helping countries reduce
malaria burden and others eliminate the disease malaria (WHO, 2015). However, the highest
burden of malaria is in Africa, especially in sub-Saharan Africa (SSA) remains unabated
although there is substantial progress towards malaria control and elimination.

Unemployment, low-income and poor construction of household are socio-economic triggering

factors that hinder the effort taken to mitigate the suffering by malaria (Id et al., 2019). In
addition, urbanization and climate change are putting more people at the risk of malaria in sub-
Saharan African countries (Caminade et al., 2014). Urbanization causes deforestation for various
land use purposes, such as construction of buildings to accommodate the urban growing
population. These bring vector species distribution-related changes leading to spatial and
temporal changes in temperature, humidity and precipitation which are expected to occur and
will affect the vector’s ecology and biology, and increase the risk of disease transmission
(Kweka et al., 2017).
Effective vector control and case management are the pillars for the malaria preventive and
control intervention. Effective vector control comprises instigating insecticide-treated nets
(ITNs) and indoor residual spraying (IRS) (Monroe et al., 2021). For case management, the
first-line treatment regimen for Plasmodium falciparum, the deadliest malaria parasite, is
artemisinin combination therapies (ACT) in nearly universally and the combination of two drugs
artemether-lumefantrine (AL) is the most common ACT in use.. Nevertheless, the threat of
emergence and rapid spread of drug-resistant parasite strains is ever continuous. A resistance
against AL has been established in Southeast Asia and in Africa recent reports from Rwanda and
Uganda appear to follow suit although in SSA the treatment remains effective so far.

9
 In general. Close surveillance of the emergence and distribution of ACT resistance is
recommended to guide policy decisions. The efficacy of national first- and second-line anti-
malarial treatments should be monitored at least once every 2 years, as recommended in the
WHO standard protocol for monitoring drug efficacy (WHO 2009). A change in an anti-malarial
medicine recommended in the national malaria treatment policy should be initiated as soon as
possible in order to prevent the spread of multidrug-resistance. When treatment failure exceed
10% policy intervention is necessitated.

1.2 Statement of the problem

In line with the above global task, Ethiopia, which currently is the 15 th in malaria case number
from 43 African countries (WHO, 2021b), has been closely monitoring AL efficacy in
nationwide sentinel sites () since the introduction of the treatment in 2004 (). This study was an
extension of the national AL therapeutic efficacy studies (TES) in one of the multiple sentinel
sites in east-central Ethiopia.
Ethiopia had experienced a devastating malaria epidemic in 1958, resulting in about three million
cases and 150,000 deaths. Since then, malaria was considered as a main concern for the health
sector. Although Ethiopia achieved an estimated 75% reduction in malaria cases from baseline of
2013 by 2020 and elimination for P. falciparum malaria in selected low transmission areas by
2020 is planned and underway (Alegana et al., 2020) malaria burden persists. the Ethiopian
national malaria strategic plan (NMSP)2021 - 2025 extended to 2030 is ongoing following
malaria programme review (MPR) to anticipating malaria elimination (Ababa, 2021).
1.3 Objective
General objective
The general objective of this study was to assess the therapeutic efficacy of AL for the treatment
of uncomplicated P. falciparum malaria in Metehara, east-central Ethiopia, and inform policy
decision.

Specific objective
The specific objectives of the study were the following:
1. To measure the clinical and parasitological efficacy of AL in uncomplicated falciparum-only
malaria patients over 6 months by determining primary and secondary endpoints: early

10
treatment failure (ETF), late clinical failure (LCF), late parasitological failure (LPF) or adequate
clinical and parasitological response (ACPR) as indicators of efficacy;
2. To evaluate the incidence of adverse events.

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2. Literature Review
1.4 Global Burden of Malaria
The target year for malaria goals was set in 2015 by the World Health Assembly to reduce
malaria incidence and mortality and the launch of WHO’s Global technical strategy for malaria
2016-2030 (WHO, 2015). From the year 2015-2020, the estimated number of cases has been
increasing repeatedly. The estimated number of cases in 2015 was 214 million which has
increased in 2020 to 229 million. However, the estimated number of deaths to some extent has
shown decrease from 438,000 in 2015 to 409,000 in 2019 but unexpectedly show significant
increase in 2020 to 627,000 due to the Covid pandemic disruption (WHO, 2015), (WHO, 2020).
The WHO African Regions hold the greatest malaria case and death rate followed by the WHO
South East Asia Region, WHO Eastern Mediterranean Region, WHO Western Pacific Region
and WHO Region of the Americas respectively(WHO, 2019).Between the years 2015-2020 the
WHO African Regions has hold up in the decreasing progress in the number of case and death
rate, still bearing the large number of case and death rate from the other Regions (WHO, 2020).
In 2015, 88% of estimated malaria case and 90% death were in WHO African Region (WHO,
2016). Similarly, in 2016 and 2017, 90%, 88% estimated cases and 80%, 93% estimated death
were verified correspondingly (WHO, Global Malaria Programme., 2017) (WHO, 2018). And in
the year 2018 and 2019, 93%, 94% case rate and 93% and 94% death rate were recorded
sequentially (WHO., 2019). In 2019, the number of case death rate elevated to from the recorded
percentages in the six years, it is possible to say that the number of case and death rate has
increased in 2019 in the Who African Region (WHO, 2020).
The WHO Africa Region account for 95% case and 96% death of malaria case and death rate in
2020 and Cabo Verde and Sao Tome and Principe have reported zero malaria deaths since 2018
(WHO, 2021b). From the WHO African region, the largest number of case rate is in Nigeria
(25%) for followed by Democratic Republic of Congo (12%), Uganda (5%) and Mozambique
(4%). Similarly, number of death rate first put on Nigeria (24%) followed by Democratic
Republic of Congo (11%), United Republic of Tanzania (5%) and Niger (4%) (Health
Organization, 2020).
The second burden of Malaria lay on the WHO South East Asia Region, in 2015 and 2016 the
rate of case was 6% and 6.1% and rate of death 5.2% and 5.7% that implies that there were
similar rate of case and death in the consecutive years (WHO. Global Malaria Programme.,
12
2017). In addition, in the year 2017, 2018 and 2019 rate of case was 4.5%, 3.3%, 2.7% and death
rate 4.2%, 2.6% and 2.2% respectively. In 2020, contributing to 2% of the burden of malaria
cases globally This has shown a progressive decrease in rate of case and death in the region
(WHO, 2021b).
The other WHO regions, Eastern Mediterranean, West pacific and America has slightly a low
rate of case and death rate, which is <3% hint at decline within the year 2015-2019. In Eastern
Mediterranean, estimated number of cases increased by 500,000 cases from 2019 to 2020 in
countries such as Sudan, Somalia and Djibouti (WHO, 2021c). Countries also in this region has
eliminate malaria. For instance, in Eastern Mediterranean region, Republic of Iran, Iraq, Oman
and Syrian Arab Republic has reported Zero malaria case before [Link] from the
Western Pacific Region, China and from Americas Region, Belize and El Salvador has recorded
Zero malaria in 2019(WHO, 2020).
Artemisinin Combination Therapies (ACTs)
The Development of Artemisinin Combination Therapies (ACTs)
In 1955 the WHO had launched Global Malaria Eradication campaign by implementing
chemotherapeutic methods in association with residual insecticides that resulted in an important
and constant reduction in malaria (Das et al., 2007). However, in many countries there has been
resurgence in malaria resulted from the rise and spread of drug-resistant parasites, the evolution
of insecticide-resistant mosquitoes (Cohen et al., 2012), Increased population density (the world
population has doubled since 1963), global warming (which has permitted the spread of vectors
into areas that were before outside their range), poverty, political instability and loss of
productivity due to infectious diseases (Hartl, 2004).
Monotherapy, extensive access of low-quality drug and misuse of anti-malarial led to the
emergence and spread of anti-malarial drug resistance (Hanboonkunupakarn & White, 2015).
After the first use of effective drug combination for the treatment of malaria by the Chinese in
Vietnam war, the interest of developing novel anti-malarial drugs were increased and led to the
development of additional combination therapies (Manuscript, 2010). Drug combinations have
been proposed with two basic importance, first the rates of malaria parasites resistant to all the
components are much reduced, such that the evolution of resistance is delayed compared with
when its components are used alone. The second importance is that the resistant combinations
will be broken down much more frequently during recombination in meiosis: the greater the
13
number of genes required to encode resistance, the greater the rate of loss (D’Alessandro &
Buttiëns, 2001). Combination therapy is now widely accepted as the way advancing to slow the
rapid emergence and spread of resistance to malaria, and to increase the useful therapeutic life of
anti-malarial drugs.
Artemisinin was first synthesized in 1971 by Tu Youyou from the plant Artemisia annua, a herb
that has commonly been used in Chinese traditional medicine and did not become widely
available outside China until the 1990s.(Tse et al., 2019).Artemisinin is obtained from the
Chinese herb sweet wormwood (Artemisia annua). The first report of the use of sweet
wormwood dates from the year 168 BC, when the plant was used by the member of the Han
dynasty for the treatment of 52 diseases; in the year 1086 it was suggested in a Chinese
compendium of medicines for the treatement of fevers and chills (Efferth, 2007). Artemisinin
derivatives have a comprehensive activity than other anti-malarial drugs, ranging from the young
ring stage of parasite development to the early schizont and reduce gametocyte carriage, thereby
limiting malaria transmission (Premji, 2009).
Artesunate plus mefloquine (ASMQ) was the first ACT to be introduced over 25 years ago in
north-western Thailand along the border with Myanmar in a context where multidrug-resistant
falciparum malaria had become difficult to treat (Nosten et al., 1994). ACTs are currently the
recommended first-line treatment for P. falciparum in all malaria endemic countries (World
Health Organization, 2020). Implementation of ACT have the greatest significance in
accomplishing the effort taken to eliminate malaria (R. Eastman & Fidock, 2009). Some ACTs
recommended by the World Health Organization (WHO) are artemether/lumefantrine,
artesunate/amodiaquine, artesunate/mefloquine, artesunate/pyronaridine (Cui et al., 2015).
More than 3.5 billion treatment courses of ACT were sold globally by manufacturers in 2010–
2020. NMPs distributed 191 million ACTs in 2020, 96% of which were in sub-Saharan Africa.
There were about 48 million fewer distributions in 2020 than in 2019 (WHO, 2021b).
Artemisinin Combination Therapy (ACTs) Resistance Mechanism in P. falciparum Malaria
Resistance to the currently available anti-malarial drugs is obstacle for malaria elimination
program in malaria endemic countries (WHO, 2019). Anti-malarial drugs mainly target the
asexual erythrocytic stages of malarial parasites that are responsible for human infection (Cui et
al., 2015). Plasmodium falciparum is one of the plasmodium species with high rate of morbidity
and mortality(Phillips et al., 2017).
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The parasite uses various resistances mechanism to deter the activity of anti-malarial drug. The
two main resistance mechanism in p. falciparum are first, due to the mutations in genes related
with drug resistance or escalating in their gene copy number (Menard & Dondorp, 2017), and the
second is a change in the parasite target due to mutations in corresponding genes(Arya et al.,
2021).Mutation on the key enzymes or transporter has been identified as factor for anti-malarial
drug resistance in P. falciparum and P. vivax by using genetic, molecular and pharmacological
methods. In P. falciparum, the drug resistance linked genes comprise P. falciparum chloroquine
resistance transporter (Pfcrt), P. falciparum multidrug resistance protein 1 (Pfmdr1), P.
falciparum dihydrofolate reductase (Pfdhfr), P. falciparum dihydropteroate synthase (Pfdhps), P.
falciparum cytochrome B (Pfcytb) and P. falciparum sodium–hydrogen exchanger gene (Pfnhe-
1) (Patel et al., 2017).
Recently, the efficacy of artemisinin derivatives (ART) is in treat due to point mutation in P.
falciparum kelch-like protein which is a primary marker of artemisinin drugs (Kumar et al.,
2018). The first ART resistance was detected in Western Cambodia resulted from monotherapy
and inappropriate administration of the artemisinin derivatives (Nsanzabana, 2019). Recently,
clonal expansions of PfKelch13 mutations detected in Rwanda and Uganda, evidence of
artemisinin partial resistance emerging independently in the WHO African Region(WHO,
2021b). Parasitic quiescence (the convergence of an adaptive process to cope with an adverse
environment and an active preparation to efficiently resume proliferation) result in delayed
parasite clearance and altered temporal response were shown to be responsible for ART
resistance(Ouji et al., 2018). In 2014, a molecular marker for artemisinin resistance was
identified: Several mutations in the PfKelch13 (K13) propeller domain were found to be
associated with delayed parasite clearance in vitro and in vivo (Subregion, 2018). The Pfk13
gene is located on the chromosome 13 with only one exon in the parasite endoplasmic reticulum
(Arya et al., 2021). Using in vitro ring-stage survival assays (RSAs) propeller domain of a P.
falciparum kelch gene 13 (codons 441 to 726), 14 independent Pfk13 mutations have been
associated with clinical delayed parasite clearance, and of these, only 5 have been confirmed by
in vivo and in vitro experiments: N458Y, Y493H, R539T, I543T, and C580Y (Associated, 2019).
Artemisinin’s have been suggested to target a very broad array of parasite proteins and seem to
disturb a number of organellar and cellular processes including hemoglobin endocytosis,
glycolysis, protein synthesis and degradation, and cell cycle regulation. Similar to CQ and other
15
aryl alcohol compounds, artemisinin derivatives mainly target the parasitic food vacuole,
interfering with heme detoxification by inhibiting hemozoin polymerization leads to heme
accumulation(Hyde, 2002). In addition, Artemisinin involves in alkylation of parasite proteins.
Together, these proceeding to oxidative stress, resulting to permanent parasite damage and
parasite death(Cui & Su, 2009). K13 mutations thought to mediate artemisinin resistance in rings
stage mainly by over-expression of the unfolded protein response leading to rapid elimination of
artemisinin and removal of artemisinin-damaged peptides (Wicht et al., 2020).
Resistance Molecular Markers in P. falciparum Malaria
Monitoring and identification of drug-resistant P. falciparum strains is paramount for the fight
against malaria. Multiplicity of infection (MOI) and genetic diversity of P. falciparum infection
are important measures for the determination of malaria transmission intensity and the impact of
malaria interventions like drug efficacy studies (Kiarie et al., 2015). Genetic diversity in the
malaria parasite rises from the recombination of distinct parasite clones during zygote formation
within the mosquito mid gut allowing the alternation of anti-malarial drug targets and increase
the parasites drug-resistant which will deter malaria treatment outcome and diminish the efficacy
of anti-malarial drugs (Abamecha, El-Abid, et al., 2020). Genetically diverse parasite species led
to persistent infections, due to drug resistant parasite strain persist after treatment as well as
increase gametocyte production due to intra-host competition (Abamecha, Abamecha, et al.,
2020).
Anti-malarial drug efficacy study helps in assessing the clinical and parasitological response
after therapy but are limited to distinguish recrudescence of resistant parasites or reinfection with
new parasite strains (Cattamanchi et al., 2003). Molecular genotyping is used increasingly to
differentiate recrudescence from reinfection in antimalarial drug efficacy studies (Laufer, 2009).
Assessing the in vitro susceptibility of P. falciparum isolates and determine the polymorphism of
molecular markers of a certain anti-malarial drug by genotype analysis based on the extensive
genetic diversity among the malaria parasite extensively polymorphic antigenic genes msp1,
msp2 and glurp is done to compare genotypic profiles of pre- and post-parasite strains (WHO,
2009). The use of molecular markers for surveillance of parasite-resistant strains has not just
made it possible to identify resistant parasite strains, but also to foresee how fast a resistant strain
is evolving and how fast it is spreading (Plowe et al., 2007).

16
The Msp1(merozoite surface protein 1), one of the most highly antigenic polymorphic proteins
(Das et al., 2007), located on chromosome 9 and play a role in erythrocyte invasion(Processing
& Invas, 2014).The msp1 synthesized by the intracellular schizont of the asexual blood and liver
stage and expressed on the surface of merozoite released rupture of infected cell (Antony., 1992).
Block 2, which is the most polymorphic part of msp1, contains the polymorphic repetitive
regions and it is a vital region for the protein for studying diversity and intragenic recombination
(Takala et al., 2002). Block 2 is grouped into three allelic families namely K1, MDA20 and
R033Alleles in K1 and Mad20 encompass different numbers of unique, tripeptide repeats and
known using the fragment length polymorphism(Chen et al., 2018). RO33 is monomorphic,
missing the tripeptide repeats observed in the other two families (Somé et al., 2018).
The msp-2 (merozoite surface protein 2) gene is located on chromosome 2 composed of five
blocks of which the most polymorphic is the central block 3(Metoh et al., 2020). The
polymorphic central domain of the gene encoding msp-2 belongs to 2 distinct families; 3D7 and
Fc27 (Mohammed et al., 2019).msp2contains wide-ranging arrays of tandemly repeated short
amino acid sequences, and this repeated epitopes facilitate for much of the antibody response of
malaria infections (Irion, 2000).
Glurp (glutamate rich protein) is exo-antigen expressed in both pre-erythrocytic, erythrocytic
stages of P. falciparum and on the surface of newly released merozoites in human host (Pratt-
riccio et al., 2013). Glurp consists one non-repetitive and two repetitive regions namely, N-
terminal nonrepetitive region (R0), central repetitive region (R1) and an immunodominant C-
terminal repetitive region (R2) (Kumar et al., 2014). R2repeat region plays an important role in
inducing protective immunity against P. falciparum malaria (Pattaradilokrat et al., 2018).
Different immunoepidemiologic studies show that, a high frequency of glurp anti-body
significantly associated within low parasite densities and protection against clinical malaria in
malaria infected person. This make glurp a finest candidate for malaria vaccine production
(Kumar et al., 2014), (Pattaradilokrat et al., 2018).
Efficacy of AL for the treatement of Uncomplicated malaria
Coartem® (artemether/lumefantrine, AL) is artemisinin-based combination therapy that has
become a mainstay of malaria treatment worldwide. In 2004, Coartem® became the first fixed
dose artemisinin combination therapy to be pre-qualified by the WHO and in 2009 approved
from the Food and Drug Administration in the US for treatment of uncomplicated malaria
17
(Stover et al., 2012). AL tablets have been included on the WHO model list of Essential
Medicines since March 2002 and on the first WHO Model List of Essential Medicines for
Children since October 2007(WHO, 2019). Zambia was the first African country with
nationwide endemic malaria to adopt AL as first-line therapy according to national malaria
treatment guidelines (Barnes et al., 2009). Ethiopia has adopted artemether–lumefantrine (AL),
an ACT antimalarial, as the first-line drug for the treatment of uncomplicated P. falciparum
malaria in July 2004 (Federal Ministry of Health (FMOH)., 2012).
Artemether and lumefantrine have different mechanism of action and take part at different points
in the parasite life cycle (Artemether- et al., 2005). Artemether have multiple mechanisms of
action, including blocking parasite transport proteins, distraction of parasite mitochondrial
function, modulation of host immune function and inhibition of angiogenesis. Lumefantrine
inhibit the detoxification of haem, such that toxic haem and free radicals bring parasite death
(Kokwaro et al., 2016).
Artemether a potent anti-malarial that absorbed quickly which result in a fast reduction in
parasite biomass and prompt symptomatic improvement and are eliminated rapidly, while the
lumefantrine concentrations that remain in the blood after the three-day treatment course abolish
any enduring parasites to avoid recrudescence(Stover et al., 2012). Artemether and lumefantrine
diminishes the existence of resistance parasite, since their different sites of action mean that
mutations resistant to both agents would be required for the organism to survive (Premji, 2009).
One of the advantages of artemether–lumefantrine combination beside the efficiency of
artemether, 100-100,000 enduring parasites when the drug is administered alone for a three-day
treatment course, and after the three-day regime lumefantrine eliminate any remaining parasites
to prevent recrudescence (Premji, 2009). Artemether–lumefantrine (AL) also have gametocidal
activity which breaks the cycle of transmission between the mosquito vector and the human host.
One study, using membrane-feeding Anopheles mosquitoes, has demonstrated a reduction in
malaria transmission following the six-dose regimen of AL (Sutherland et al., 2005).
The efficacy of AL combination is strongly influenced by the wide variation in the
pharmacokinetics of lumefantrine among individuals. Food (especially dietary fat) improves the
bioavailability of artemether and lumefantrine, though this effect is more significant for
lumefantrine (White et al., 1999). Administration of AL to healthy volunteers with the uptake of
high-fat meal increases the bioavailability of artemether and lumefantrine by two-fold and 16-
18
fold, respectively, compared with the fasted state (Ezzet, 2000).As its absorption is enhanced by
concomitant intake of fatty foods, treatment failures with this combination might be due to
insufficient absorption of lumefantrine. For instance, In Cambodia, studies of artemether–
lumefantrine were conducted between 2001 to 2004. High treatment failure rates were observed
in 2001 (26.1%) and 2002 (28.9%); however, in 2003, when treatment was given with fatty
foods, the failure rate decreased to 13.5% (Denis et al., 2006a).
The other advantage of AL for patients which is not already resistant to one or more of the drugs,
AL reduces the chance of survival by a resistant parasite, since their different sites of action
mean that mutations resistant to both agents would be required for the parasite to survive
(Artemether et al., 2005). Moreover, pediatric formulation of AL tailored to the needs of children
with P. falciparum malaria was developed by the collaboration of Novartis and the Medicines for
Malaria Venture (MMV). By this, the previous standard of care such as crushing standard tablets
of AL, which is problematic for caregivers and difficult for the treatment of sick children, while
the crushing procedure risked loss of drug and the bitter taste intended that child might spit it out
are overcome (Abdulla & Sagara 2009).
A systematic review conducted by Derbie and his colleague on 39 therapeutic efficacy studies of
AL, PCR uncorrected 87% (95% CI: 85-90%) and PCR corrected 97.0% (95% CI: 96-98%) were
shown (Derbie et al., 2020). A meta-analysis conducted on anti-malaria treatement out come in
Ethiopia suggests the high efficacy rate of AL for the treatment of uncomplicated malaria 98.1%
(97.0–99.2), p < 0.001, I2 = 72.55(Gebreyohannes et al., 2017). A TES study conducted in
Metehara states high efficacy of AL with the PP analysis PCR-uncorrected cure rate of was
97.6% (95%CI: 93.6–99.5) and the PCR-corrected cure rate was 98.8% (95%CI: 93.5–100%)
(Nega et al., 2016).

First- and Second-Line Anti-Malarial Drug for Uncomplicated P. falciparum Malaria

Malaria endemic countries have first- and second-line anti-malaria drug guidelines in accordance
with the WHO approved anti-malaria drug list. The objective of all anti-malaria drug is to cure
the infection as quickly as possible and to avert before it advance to severe disease(WHO,
2021a). Currently, artemisinin combination therapies (ACTs) are implemented as the first- and
second-line anti-malarial drug for the treatment of uncomplicated P. falciparum malaria globally
(Organization, n.d.). ACT is a combination of a rapidly acting artemisinin derivative with a

19
longer-acting (more slowly eliminated) partner drug. The artemisinin component rapidly clears
parasites from the blood and the longer-acting partner drug eliminate the remaining parasites and
offers protection against development of resistance to the artemisinin derivative (Eastman and
Fidock 2009).
The first-line treatments used in most African countries for P. falciparum are artemether-
lumefantrine (AL) and artesunate-amodiaquine (AS-AQ), with some countries’ treatment
policies also allowing for the use of dihydroartemisinin-piperaquine (DHA-PPQ) (WHO 2019).
Similarly, the southeast Asia, Latin America, Mediterranean and Western Pacific countries they
use ACT, such as DHA-PPQ, AS-AQ, AS-MQ as their first-line anti-malarial drug (World
Health Organization., n.d.).
After the first ART resistance was detected in Western Cambodia the efficacy of artemisinin
derivatives and artemisinin combination therapy fell to question. (Hanboonkunupakarn & White,
2015). To deter such resistance in the other malaria endemic countries the WHO recommended
regular monitoring to Anti-malarial drug through therapeutic efficacy study to assess the clinical
and parasitological response after therapy and to evaluate adverse events (Report on Antimalarial
Drug Efficacy, Resistance and Response, 2019). In Ethiopia, a three-day regime of AL
(artemether 20mg and lumefantrine 120mg in each tablet) and single dose primaquine (PQ) is the
first-line anti-malarial drug for the treatment of uncomplicated P. falciparum malaria (FDRE-
MoH, 2018).Second-line treatment for uncomplicated malaria is used when the first-line
treatment is unavailable or when the first-line medication fails or does not work. In Ethiopia, oral
quinine is the second-line therapy for both P. falciparum and P. vivax (Federal Ministry of
Health (FMOH) 2012.

20
3. Materials and Methods
3.2. Study site
The study was conducted in Eastern Shewa zone health department, Metehara town health
center, Ethiopia. Metehara is an administrative town of Fentale district in Oromia Regional state
of Ethiopia. The area is located in the Great Rift Valley, about 210km east of Addis Ababa, the
country’s capital. Its coordinate is 8°540’ N39°550’E and average elevation is 947m (3,107ft),
with time zone of EAT (UTC+3). Rivers Awash and Germama, and Lake Basaka are important
water bodies in the district. An estimated of total population of 39, 585 live in Metehara town
from the two Kebeles.
Metehara is one of the sentinel sites of malaria TES in east-central Ethiopia. The town has estate
irrigation by using the nearby rivers for the industrial cultivation of sugarcane, and this in turn,
suits breeding of the Anopheles mosquito. Transmission of malaria in this area occurs year-
round.
3.1 Study design
This surveillance study was a one-arm prospective evaluation of clinical and parasitological
responses to directly observed treatment for uncomplicated P. falciparum malaria. People with
uncomplicated P. falciparum malaria who met the study inclusion criteria were enrolled, treated
with AL on site for 28 days. The follow-up was consisted of a fixed schedule of check-up visits
and corresponding clinical and laboratory examinations. Based on the results of these
assessments, the patients were classified as having therapeutic failure (early or late) or an
adequate response. The proportion of patients experiencing therapeutic failure during the follow-
up period was used to estimate the efficacy of the study drug.
3.3. Sample size
As the treatment failure rate to AL, in the area is unknown, the population was consisted of
patients with uncomplicated P. falciparum malaria attending the study health clinics 80 patients
were chosen whose age is above 6 months. All adult patients were signing an informed consent
form for participation. Parents or guardians was giving informed consent on behalf of children.
Children over 12 years of age was signing an informed assent form.

21
At a confidence level of 95% and a precision around the estimate of 5%, a minimum of 73
patients must be included. With a 20% increase to allow loss to follow-up and withdrawals
during the 28-day follow-up period.
3.4. Timing and duration of study
Transmission of malaria in this area occurs year-round. Thus, the study was conducted from
November, 2020 to March, 2021 which is the peak malaria transmission season.
3.5. Study Subjects, inclusion criteria, exclusion criteria
3.5.1. Study Subjects
The study population consisted of febrile patients visiting the outpatient department of the health
center who fulfilled the inclusion criteria set by the WHO for the assessment and monitoring of
antimalarial drug efficacy for the treatment of uncomplicated falciparum malaria.
3.5.2. Inclusion criteria
Patients age ≥ 6 months; mono-infection with P. falciparum detected by microscopy; parasitemia
≥ 1000/μl asexual forms; presence of axillary or tympanic temperature ≥ 37.5°C or oral; history
of fever during the past 24 h; ability to swallow oral medication; ability and willingness to
comply with the study protocol for the duration of the study and to comply with the study visit
schedule; and informed consent from the patient or from a parent or guardian in the case of
children and a negative pregnancy test or not breastfeeding.
3.5.3. Exclusion criteria
The exclusion criteria included presence of general danger signs in children aged under 5 years
or signs of severe falciparum malaria according to the definitions of the WHO; mixed or mono-
infection with non-falciparum Plasmodium spp. detected by microscopy; presence of severe
malnutrition defined as a child whose growth standard is below –3 z-score, has symmetrical
oedema involving at least the feet or has a mid-upper arm circumference < 110 mm). Febrile
conditions due to diseases other than malaria like measles, acute lower respiratory tract infection
or severe diarrhea with dehydration or other known underlying chronic or severe diseases such as
cardiac, renal and hepatic diseases, HIV/AIDS; having a regular medication, which may interfere
with antimalarial pharmacokinetics; history of hypersensitivity reactions or contraindications to
any of the medicine(s) being tested or used as alternative treatment(s) and a positive pregnancy
test or breastfeeding were additional exclusion criteria.

22
3.6. Data collection and sampling technique
3.6.1. Recruiting of study participants
Patients who fulfilled the inclusion criteria were recruited and a brief explanation about the study
was made.
3.6.2. Physical examination
A standard physical examination, medical history, demographic information and contact details
were registered at baseline (day 0 before dosing) and on days 1, 2, 3, 7, 14, 21, 28.
3.6.3. Laboratory examination
According to the WHO protocol 2009, capillary blood samples were collected from patients
aseptically and labeled anonymously (i.e., code number and follow up day). Thick and thin blood
films were prepared at day 0 (D0), stained with fresh 10% Giemsa stain and examined for the
eligibility of inclusion criteria. If the patient was eligible, thick blood films were examined on
day 2, 3, 7, 14, 21 and 28 or on any unscheduled day. Parasite count was done on the number of
asexual parasites observed against 200 white blood cells (WBCs). Parasite density was
calculated by multiplying average number of parasite count by 8000 WBCs and dividing average
no of WBCs count (200 WBCs). Hemoglobin/hematocrit was determined on days 0 by using the
Microhematocrit capillary(KIMBLE® Micro-Hematocrit Capillary Tube, Heparinized, 0.5 x 75
mm, Case of 1200, 60 mm).
3.7. Drug administration
Three days of drug was administered based on age/bodyweight under direct supervision of the
clinical team. Before treatment, axillary temperature was measured and recorded. A participant
was observed for 30-60 minutes after the first dose. When there is vomiting, the patient was
retreated with another dose and observed for another 30 minutes. If vomiting had happened
again, he/she was excluded from the study, if not they were given a second dose with extra (in
case they vomited at home), and if were febrile, antipyretics were provided.
3.8. Data analysis
Data were double entered into the WHO Excel spread sheet designed for therapeutic efficacy
data. Data were also entered into IBM SPSS (version 20) software to calculate descriptive
statistics (mean, standard deviations, percentages). Independent t-test was used to check the
presence or absence of statistically significant mean differences between the continuous

23
variables among age groups. All comparisons were performed at 95% CI and significance level
of 0.05.
3.9. Ethical Consideration
The study protocol was approved by College of Natural Sciences Institutional Ethics Review
Board, Addis Ababa University and by the Ethical Review Committee of Ethiopian Public
Health Institution (EPHI), Ethiopia. Informed consent was obtained from adult participants and
for min ors parental/guardians agreed after assents. Data collected from each participant and
laboratory results were kept confidential and used only for the research purpose.

24
 4. Results
4.1 Participants
A total of 2332 (1187 male and 1145 female) malaria suspects visit MHC for malaria diagnosis
between December to March, 2020/2021. Of this 178(7.7%) were positive and the rest
2154(92.3%) were negative. Among 178 positive 102(57.3%) were P. falciparum and 76(42.6%)
were P. vivax. Out of 102 P. falciparum positive 89 were eligible and targeted for the study, 9
refused consent due to their mobile working area and 80 patients were enrolled in the study and
73 has completed the follow up. After the follow up study completed, the positive slides were
taken to Adama Regional Laboratory for quality control and cross-check inspection. Among 73
slides 9 slide found as Mixed-infection with P. vivax. To increase the accuracy of the study a
third person cross check the 9 slides in EPHI and found out Mixed-infection with P. vivax and
excluded from the study.
At baseline, the majority of the patients with P. falciparum mono-infection were male 43(62%),
and females 28(38%). Among those 13(18.3) were <5, 24(33.8) were between the ages of 5-14
and 34(47.9%) were >15. Although 26(36.6) patients were febrile during screening; the rest had
a self-reported history of fever within the previous 24 hours. Mean body temperatures were
37.7±1.3(<5), 37.7±1.38(5-14), 36.7±0.92(>15), and mean Hb 8.6±2.18, 9.88±2.01, 11.6±1.42
for each age group respectively. The total mean bodyweight was 36.8±19.9.
The baseline mean Hb level was 10.5±2.14 and 45 patients (63.3%), 28 children (below 14 years
of age) and 17 adults, were anemic (25 moderate and 20 mild). Out of 45 anemic patients, 25
were males. The total baseline mean parasitemia was 10,627±20,736.7. There was significant
variation between mean parasitemia for children (<5) (3754.62±4435.472) and those between the
ages of (5-14) (14278.08±27981.34). There was only one patient with parasitemia>100,000/μl.
The gametocyte carriage rate was 8.4% with gametocyte numbers ranging from 199-1287/μL of
blood. In addition, 29(40.8%) study participants reported a previous history of clinical malaria
and 38(53.3%) of the participants confirmed the availability of a bed net but 27(38%) utilize the
bed net.
Figure .1. Screening, enrollment, follow-up and treatment outcomes of P. falciparum malaria
patients in Metehara Health Center [ACPR - Adequate Clinical and Parasitological Response, ETF -
Early Treatment Failure, LCF - Late Clinical Failure, LPF - Late Parasitological Failure ]

25
 Febrile Patients Screened at Health Center
N=2332
2,154 Negatives for
178 Positive Malaria
Malaria
P. falciparum-102
P. vivax-76

80 P. falciparum Malaria
was enrolled

ETF, LCF and LPF Lost to follow up

Involuntary protocol ACPR
n=7
violation(mixed-
N=64
n=0 n=7 infection)

n=9

Table 1: Baseline characteristics of the study participants at Metehara Health Center, East-
Central Ethiopia, 2021

Variables Age Category

<5 5-14 >15 Overall
Mean age (range), years 3±1.2 9±2.24 30±11.9 18±14.6
Sex Male, n (%) 6(53.8) 11(45.8) 26(76.5) 43(62)
Female, n (%) 7(46.2) 13(24.1) 8(23.5) 28(38)
Total 13 24 34 71
Mean body temperature, 37.7±1.3 37.7±1.38 36.7±0.92 37.2±1.25
ºC ±SD
Mean bodyweight ±SD 10.9±3.08 23.1±6.72 55.4±9.75 36.8±19.9
Mean Hb level, g/dL, 8.6±2.18 9.88±2.01 11.6±1.42 10.5±2.14
±SD
Mean parasitemia per 3754.62 14278.08 10679.03 10,627
μl±SD ±4435.472 ±27981.343 ±18193.26 ±20,736.7

26
Gametocyte presence, n 1(7.7) 3(12.6) 2(5.8) 6(8.4)
(%)
Bed net utilization (%)
Yes 30.8 25.0 50.0 40.8
No 69.2 75.0 50.0 59.2
Previous malaria attack
%) Yes 23.1 33.3 52.9 38.0
No 76.9 66.7 47.1 62.0

4.2. Primary Endpoint

Of the 80 patients treated, 7 were lost-to-follow-up, 9 patients result found as mixed infection
during cross check therefore excluded from the study and adequate clinical and parasitological
response (ACPR) was recorded for the 64. The ACPR was 100% (64/64; 95% CI: 95.1-100.0)
(Table 2) with no ETF, LTF, LPF as in Kaplan–Meier analyses (Fig. 1).
Table 2: Treatment outcomes based on Per Protocol analysis among patients treated with
artemether lumefantrine at Metehara Health Center

Treatment Frequency in each age (year) category

outcome <5 5-14 >15 Overall

ACPR 33(51.5%) 27(42.1%) 4(6.3%) 64(100)

ETF 0(0) 0(0) 0(0) 0(0)

LTF 0(0) 0(0) 0(0) 0(0)

LPF 0(0) 0(0) 0(0) 0(0)

LF 0(0) 2(28.6%) 5(71.4%) 7(9.9%)

W 0(0) 0(0) 0(0) 0(0)

ACPR - Adequate Clinical and Parasitological Failure, ETF Early Treatment Failure, LTF Late Treatment Failure,
LPF - Late Parasitological Failure, LF Loss-to Follow-up, W – Withdrawal

4.3. Secondary Endpoint

Parasite clearance

At baseline, 25.35% (18/71) of the study participants were severely parasitemic (>10,000
parasites/μl), while the rest 74.65% (53/71) were found moderately parasitemic (1000–9999
27
parasites/μl). Among 18 study participants with severely parasitemic 50% (9/18) were >15 age,
44.1(8/18) were 5-14 age and 5.5% (1/18) were <5 age respectively. During the consecutive
three days of drug regime the parasite decline to 0 from baseline to day 2.

Fever clearance

At the day of enrollment febrile individuals, ≥37.5°c axillary temperature was 48.45% (29/71)
and decreased to 14.08% (10/71) on day 1, 5.6% (4/71) on day 2 and 1.48(1/71) on days 3.
Accordingly, fever clearance was85.91 (61/71) on day 1, 94.36% (4/71) on day 2, 98.6% (1/71)
on day 3 and no febrile case was detected onwards. Fever case among severely parasitemic
patients was 33.3% (6/18) and among the moderately parasitemic.

Gametocytemia Clearance

At baseline only 8.4% (6/71) gametocyte cases were detected. Among the 6 participants with
gametocyte carriage 12.5% (3/24) detected in 5–15 yrs, 5.9% (2/34) detected in >15 years and
7.7% (1/13) was detected in <5 age group. The proportion of gametocyte carriage per total study
participants was declined from 8.4% (6/71) on day 0 to 5.6% (4/71) on day 1, 4.2% (3/71) on day
2 and 1.4% (1/71) on day 3 and completely disappeared on day 7.

4.4. Advert events

At baseline, the patients reported some of the common signs and symptoms of malaria. All
patients reported headache. Others signs and symptoms that could possibly be associated with
AL included anorexia (29%), nausea (21.1%), dizziness (19%), abdominal pain (14.4%),
diarrhea (13.3%), vomiting (16%) and cough (2.2%) (Table 3). All the probable adverse events
disappeared with the clearance of parasitemia within the 3 days.

28
Table 3: Probable adverse events at baseline with their frequency in percent. December to March
2020/2021.
Probable Adverse Event Frequency (%)
Anorexia 29
Nausea 21.1
Dizziness 19
Abdominal Pain 14.4
Diarrhea 13.3
Vomiting 16
Cough 2.2

Figure.2. Survival analysis of 28-day cure rate of P. falciparum for Artemether lumefantrine,
Metehara, December to March 2020/2021.

29
 dĞŵƉĞƌĂƚƵƌĞs Ɛ&ŽůůŽǁ ƵƉĚĂLJƐ
ϰϭ

ϰϬ

ϯϵ

ϯϴ

ϯϳ

ϯϲ

ϯϱ
Ϭ Ϯ ϯ ϳ ϭϰ Ϯϭ Ϯϴ
ϭ
Figure.3. Mean body temperature on the first three follow-up days.

' ĂŵĞƚŽĐLJƚĞs Ɛ&ŽůůŽǁ ƵƉ

ĚĂLJƐ
ϮϬϬ
Ϭ
ϭϲϬ
Ϭ
ϭϮϬ
Ϭ
ϴϬ
Ϭ
ϰϬ
Ϭ
Ϭ
Ϭ Ϯ ϯ ϳ ϭϰ Ϯϭ Ϯϴ
ϱ
Figure.4. Number of patients with gametocytes on each follow-up day.

30
4. Discussion
This study presented the 28-day cure rate of a standard six-dose of Coartem as close to 100% in
treating uncomplicated P. falciparum malaria, with rapid clearance of fever and parasitemia
within the first three days. For PP analysis, the PCR-uncorrected cure rate of Coartem among the
study participants were 100% (64/64; 95% CI: 95.9-100.0). Similar high efficacy findings were
already reported elsewhere in Ethiopia, and in sub-Saharan Africa (Derbie et al., 2020). Meta-
analysis in Anti-malarial treatment outcomes in Ethiopia, Among 21 publications reported the
average efficacy of 98.1%, which is almost similar to the present study finding(Gebreyohannes
et al., 2017).

The presence of parasitemia on D3 is key indicator to suspect artemisinin resistance(Mekong,

2015). Since Artemether a potent anti-malarial that absorbed quickly which result in a fast
reduction in parasite biomass and prompt symptomatic improvement and are eliminated rapidly
(Stover et al., 2012), in this study the absence of ETF confirms non-existence of probable
artemisinin-resistant P. falciparum strains. Similarly, during the study there were no LTF and
LPF present. This is one indicates that the current study well tolerance and high efficacy to AL
against uncomplicated malaria in Metehara. The adjusted cure rate at day-28 was 100% each for
<5 children, 5-14 and >15 age group. There was no significant difference in cure rate of each age
groups.

The total baseline mean parasitemia was 10,627±20,736.7. Parasitaemia is correlated with the
severity of malaria, making it a crucial factor in determining the sort of therapy to begin.
Additionally, it has consequences for epidemiology since it shows level of localized transmission
intensity. malaria endemicity in the study area expected to be holoendemic, despite the fact that
the extent of the endemicity has not yet been fully assessed. The duration and intensity of malaria
fluctuate depending on the amount and duration of rainfall(Birhanu et al., 2018), according to
statistics from the local health office the quantity of transmission was throughout the whole
season but number of case decrease during the study since the malaria transmission peak season
pass.

The primary clinical symptom of malaria that causes significant pain is fever. Each participant in
this study had a baseline mean body temperature of 37.2±1.25 C, making them all deemed
febrile. Between children and adults, there was discernible difference in baseline mean body
31
temperature. During the study regime well-tolerated fever clearance was observed. After the
intake of the drug at the base line all participants clear fever on day 1 and on ward and this is
comparable to other results(Nega et al., 2016), (Teklemariam et al., 2017). In contrast to results
from Southeast Asian nations where delayed fever clearance of AL, the rapid fever-resolving
ability of AL is seen in other efficacy tests carried out in Ethiopia and elsewhere in sub-Saharan
Africa.

Artemisinin derivatives have a comprehensive activity than other anti-malarial drugs, ranging
from the young ring stage of parasite development to the early schizont and reduce gametocyte
carriage, thereby limiting malaria transmission (Premji, 2009). Artemether–lumefantrine (AL)
also have gametocidal activity which breaks the cycle of transmission between the mosquito
vector and the human host. One study, using membrane-feeding Anopheles mosquitoes, has
demonstrated a reduction in malaria transmission following the six-dose regimen of AL
(Sutherland et al., 2005). In this study from baseline, the gametocyte clear on day 2 but one case
persists up to day 3 and completely disappear on day 7 and on ward.
No serious adverse events were noted; the majority of the reactions were already recognized by
the manufacturer as common adverse reactions and documented with the food and drug
administration. the majority mentioned joint discomfort, weakness, headache, cough, Anorexia,
stomach ache. With the parasite cleared, those small symptoms were quickly gone. The results of
other studies are consistent with the absence of any major adverse events following Coartem
treatment in the current investigation (Nega et al., 2016), (Teklemariam et al., 2017).
Food (especially dietary fat) improves the bioavailability of artemether and lumefantrine (White
et al., 1999). However, in the current study, AL was administered without giving fatty food; only
biscuits to children were provided earlier drug intake in the outpatient. This is one of the
probable limitations in this study.

32
5. Conclusion
The current result showed the high efficacy of Coartem that suggests the continuation of the drug
as first-line for the treatment of uncomplicated P. falciparum malaria in the study area. The AL
continues to be a highly effective treatment for uncomplicated P. falciparum infection in the
study location even after several years of being widely available throughout the nation. Similar
study has been conducted in the study area in 2016 and similar result was recorded. This study
recommends frequent efficacy study in the area as recommended by the WHO.

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