PRACTICAL ASPECTS OF IN VIVO ANTIMALARIAL DRUG EFFICACY TESTING IN THE AMERICAS

TRENTON K. RUEBUSH II National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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WILMER MARQUIÑO National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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JORGE ZEGARRA National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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DANIEL NEYRA National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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RODOLFO VILLAROEL National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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JUAN CARLOS AVILA National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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CÉSAR DÍAZ National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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EFRAÍN BELTRÁN National Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Naval Medical Research Center Detachment, Lima, Peru; Instituto Nacional de Salud Lima, Peru; Programa de Control de Malaria y Otras Enfermedades Metaxénicas Ministerio de Salud, Lima, Peru; Programa Nacional de Control de la Malaria Ministerio de Salud Pública y Previsión Social, La Paz, Bolivia; Servicio Nacional de Erradicación de la Malaria Ministerio de Salud Pública, Quito, Ecuador

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The World Health Organization (WHO) has developed guidelines for in vivo antimalarial drug efficacy testing for Plasmodium falciparum and Plasmodium vivax in areas with low-to-moderate transmission, such as the Americas. These guidelines are used widely by ministries of health and national malaria control programs to assess the efficacy of their first-line and second-line drugs for the treatment of malaria and to provide the information necessary to update national malaria treatment policies. Following the WHO guidelines, we have conducted in vivo efficacy trials with a variety of drugs and drug combinations against P. falciparum and P. vivax at 13 sites in Peru, Bolivia, and Ecuador. Based on these experiences, we have identified several modifications that we believe should be made in the WHO recommendations to make them more suitable to the relatively low levels of P. falciparum transmission in the Americas and to the logistic challenges of carrying out such studies in sparsely populated areas, such as the Amazon Basin. These include changes in inclusion and exclusion criteria, in enrollment and follow-up procedures, and in the measurement of study outcomes.

Author Notes

Reprint requests: Trenton K. Ruebush II, NMRCD, Unit 3800, APO AA 34031, USA, Telephone: 0051-1-561-2733, Fax: 0051-1-561-3042, E-mail: ruebush@namrid.sld.pe
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