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COMPARATIVE EFFICACY OF CHLOROQUINE AND SULFADOXINE-PYRIMETHAMINE FOR UNCOMPLICATED PLASMODIUM FALCIPARUM MALARIA AND IMPACT ON GAMETOCYTE CARRIAGE RATES IN THE EAST NUSATENGGARA PROVINCE OF INDONESIA

The efficacy of chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) was evaluated in 89 subjects greater than one year of age with uncomplicated P. falciparum malaria in the East Nusatenggara Province of Indonesia. Fever clearance time was longer in the SP group than in the CQ group. However, parasite clearance time was extended in subjects who received CQ compared with those who received SP. Major adverse events were not observed in either group, and no hospitalizations were required during the study. Treatment failure rates at day 28 were 69% for CQ and 8.5% for SP. In both treatment groups, gametocytemia developed during the follow-up period, but was more pronounced in the SP group, peaking at 94% on day 7. Regardless of treatment group, children < 10 years of age had significantly higher treatment failure rates than subjects 10 years of age (relative risk = 2.49), suggesting that acquired immunity influenced treatment outcomes in the presence of parasite drug resistance. Although a highly effective alternative to CQ for clearing infection, SP treatment also presented some potential drawbacks (e.g., increased and persistent gametocytemia). Replacement of CQ with SP as a first-line therapy, either alone or in combination with CQ, in those areas of Indonesia with high levels of CQ resistance should significantly improve treatment outcomes, particularly in vulnerable populations lacking clinical immunity. More efficacious and rapidly acting asexual stage treatments are generally associated with increased gametocyte clearance and combination therapy in areas where drug resistance is high or emerging may provide an additional means for reducing transmission.

Received May 28, 2003. Accepted for publication December 10, 2003.

Acknowledgments: We thank Dr. F. J. Laihad (Malaria Sub-Directorate, Ministry of Health, Jakarta, Indonesia), Dr. Paul Manoempil (Head of the District Health Administration, Alor Regency), and the staff of the Kenarilang Health Center (Drs. Andi Medianto and Made Birawan and all nurses, laboratory technicians, and field workers) who participated in this study. We also thank Dr. Is S. Ismid (Department of Parasitology, Faculty of Medicine, University of Indonesia) for her support and encouragement and all GTZ/SISKES administrative staff in Kupang and Alor for their kind cooperation and assistance.

Financial support: This investigation was supported by the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ), Improvement of the District Health System in East Nusa Tenggara (GTZ/SISKES).

Authors’ addresses: Inge Sutanto, Department of Parasitology, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Jakarta 10430, Indonesia. Sri Supriyanto, Communicable Diseases Control, Ministry Health of Indonesia, Jl. Percetakan Negara No. 29, Jakarta 10560, Indonesia. Paul Rückert, German Agency for Technical Co-operation (GTZ), Aula Utama Eltari Lantai I, Jl Polisi Militer No. 3, PO Box 1217, Walikota Baru, Kupang 85000, Indonesia. Purnomo, Jason D. Maguire, and Michael J. Bangs, U.S. Naval Medical Research Unit No. 2, FPO, AP 96520-8132 or JI. Percetakan Negara No. 29, Jakarta 10560, Indonesia, E-mail: bangsmj{at}namru2.med.navy.mil.

Reprint requests: Inge Sutanto, Department of Parasitology, Faculty of Medicine, University of Indonesia, Salemba Raya No. 6, Jakarta 10430, Indonesia, Telephone: 62-21-310-2135; Fax: 62-21-391-4607. E-mail: inge_sutanto2{at}yahoo.com.

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