Chloroquine-resistant Plasmodium vivax in Pakistan: an emerging threat
Authors: Ammara Khan, Faizan J Godil, Rabia Naseem
Journal: The Lancet Global Health (2016)

Pakistan has a population of 194 million people, of which approximately 182 million live in malaria-endemic regions.1WHOWorld malaria report 2015. World Health Organization, Geneva2015http://www.who.int/malaria/publications/world-malaria-report-2015/wmr2015-profiles.pdf?ua=1Google Scholar In Pakistan there are 500 000 new cases of malaria and 50 000 deaths caused by malaria each year.2Khattak AA Venkatesan M Nadeem MF et al.Prevalence and distribution of human Plasmodium infection in Pakistan.Malar J. 2013; 12: 297Crossref PubMed Scopus (58) Google Scholar Plasmodium vivax is the culprit in 88% of malaria admissions,1WHOWorld malaria report 2015. World Health Organization, Geneva2015http://www.who.int/malaria/publications/world-malaria-report-2015/wmr2015-profiles.pdf?ua=1Google Scholar although Plasmodium falciparum often takes the spotlight, given its more severe course. Chloroquine has long been the drug offered to patients with unconfirmed malaria and those diagnosed with P vivax infection. Given the rise of drug resistance in many infectious agents due to poorly regulated drug use, it is no surprise that resistance has occurred in the organism that so frequently infects us. The time has come to recognise the threat of chloroquine-resistant P vivax in Pakistan, an entity that has been largely ignored. Data on chloroquine resistance from Pakistan is scarce, even in the most recent global analysis.3Price 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 (258) Google Scholar Nevertheless, in 2013, the emergence of the F1076L mutant of the pvmdr1 gene—the mutation responsible for chloroquine resistance—in P vivax in Pakistan highlights the imminent threat of resistant Plasmodium.4Khattak AA Venkatesan M Khatoon L et al.Prevalence and patterns of antifolate and chloroquine drug resistance markers in Plasmodium vivax across Pakistan.Malar J. 2013; 12: 310Crossref PubMed Scopus (27) Google Scholar In 2015, the first case of resistance was identified in a pregnant woman, and it was cured after switching to a combination of artemether and lumefantrine.5Waheed AA Ghanchi NK Rehman KA Raza A Mahmood SF Beg MA Vivax malaria and chloroquine resistance: a neglected disease as an emerging threat.Malar J. 2015; 14: 146Crossref PubMed Scopus (13) Google Scholar Implementation of the Roll Back Malaria initiative by Pakistan's Directorate of Malaria Control is the latest government attempt to eradicate malaria. It includes key elements of malaria control and prevention, but there is no mention of facilitating research on the Plasmodium gene polymorphisms in our population. We have reached an age of resistance, in which monotherapies and simple prevention are insufficient to combat the new generation of genetically diverse microorganisms armed with mutations that we have not prepared for. Our national malaria policy addresses chloroquine-resistant P falciparum, first identified 30 years ago, but has no mention of resistant P vivax or management guidelines for resistant P vivax infections. Given the bleak future in the presence of a malaria parasite that is resistant to the most common drug, relevant government-funded research is necessary to understand the burden of resistant malaria in Pakistan, and old guidelines have to be revised before an epidemic takes control. We declare no competing interests.