Background
Plasmodium vivax is the most widely distributed human malaria parasite and the dominant species outside of Africa. The estimated annual global burden of
P. vivax is about 14.3 million clinical infections [
1]. Most tropical regions in the Southeast Asia, Middle East, and the Western Pacific account for about 80–90% of vivax malaria cases outside of Africa [
2]. Although it was historically considered to cause benign infection, severe cases and morbidity due to
P. vivax have notably been reported [
3]. Several factors associated with
P. vivax infection; includin
g the presence of dormant forms in the liver, the early production of gametocytes, and also the emergence of chloroquine (CQ) resistance, impose major challenges for malaria control programmes.
For decades, CQ has been the mainstay of treatment of vivax malaria. In combination with primaquine, it is very effective against the acute disease and the hypnozoites. However, this status is progressively threatened by the spread of CQ-resistant
P. vivax. The first report of
P. vivax resistance to CQ was published in 1989 in Papua New Guinea [
4]. Since then, CQ-resistant
P. vivax has been reported from different endemic countries in Southeast Asia, South Asia, the Middle East, the Americas, and the East Africa [
5,
6]. Since CQ-resistant
Plasmodium falciparum has spread throughout malaria-endemic regions and taken many lives, it seems likely that the same situation will occur in near future with
P. vivax. Therefore, to avoid the occurrence of the same scenario, extensive research must be done to evaluate the status of CQ resistance. Unlike
P. falciparum, detection of CQ-resistant
P. vivax is extremely difficult, because recurrent infections can arise from recrudescence, relapses from hypnozoites or a new infection. Due to the difficulties involved in determining the in vivo treatment failure for
P. vivax infection, molecular markers seem to be helpful for monitoring and predicting the occurrence of drug resistance in
P. vivax.
The exact molecular mechanisms of CQ resistance in
P. vivax remain unclear and it is likely that multigenic loci are involved in this process.
Multidrug resistance 1 (
pvmdr1) and Plasmodium vivax chloroquine resistance transporter, putative (pvcrt-o), orthologues of genes involved in CQ resistance in
P.
falciparum, have been proposed as potential molecular markers; although their exact role in CQ resistance needs to be fully determined [
7‐
10]. The
pvmdr1 gene is located on chromosome 10 and contains 24 single nucleotide polymorphisms (SNPs). Y976F and F1076L mutations in
pvmdr1 have been reported as possible molecular markers of CQ resistance in
P. vivax [
11,
12]. In vitro data showed a significant increase in IC50 value for CQ that correlated with Y976F mutation in
pvmdr1 gene [
11]. However, different studies show conflicting results about the role of Y976F and F1076L mutations in CQ resistance. Furthermore, there are some evidences that suggest the involvement of other mechanisms, such as gene amplification and changes in expression levels in the occurrence of CQ resistance in
P. vivax [
13‐
15]. However, it seems likely that the
pvmdr1 mutations at Y976F and F1076L positions may provide a useful tool to monitor the occurrence and spread of CQ resistance in
P. vivax due to its variability and spatial patterns. Therefore, surveillance of these potential molecular markers in different endemic areas would be helpful to inform health policy about genetic changes of parasite in response to CQ pressure before the emergence of drug resistance phenotypes.
In 2020, Iran reported zero indigenous cases for the third consecutive year and is considered as malaria eliminated region [
16]. However, imported cases from neighbouring countries, including Pakistan and Afghanistan could be the potential source of introducing the drug-resistant strains. The first report of CQ-resistant
P. vivax in Pakistan was published in 2015 [
17]. It could be an alarm signal for malaria control strategies in Iran and highlights the importance of continuous surveillance of the related molecular markers of anti-malarial resistance. Although molecular methods may not be the most effective approach to assess drug resistance in
P. vivax, reliable molecular markers allow to predict the molecular change of parasite in response to drug pressure before the appearance of resistance phenotype. There is a paucity of studies that have investigated the associated molecular markers with CQ resistance in circulating
P. vivax isolates from Iran. Therefore, this study was designed to evaluate the current prevalence of Y976F and F1076L mutations in
pvmdr1 gene as the potential markers to monitor CQ resistance in the collected
P. vivax isolates from Iran. In this study, a simple PCR–RFLP method was developed to assess these mutations and applied different control samples to standardize this molecular analysis.
Discussion
In Iran, CQ remains generally effective against
P. vivax [
20] and this drug remains the main drug of choice for blood-stage treatment of uncomplicated
P.
vivax patients. However, the large influx of imported cases from Pakistan and Afghanistan increases the risk of introducing CQ resistance strains which becomes a major challenge for malaria elimination in Iran. A case report of CQ-resistant
P. vivax infection in Pakistan [
17] may be an emerging threat and support the importance of monitoring drug resistance in endemic regions of Iran bordering Pakistan. To address the potential emergence of CQ-resistant
P. vivax in imported cases from Pakistan, mutations of candidate resistance marker in
pvmdr1 gene were studied. In this study, a simple PCR–RFLP method was developed and validated to assess molecular markers of CQ resistance in
P. vivax isolates. A successful elimination programme requires specific tools to monitor the genetic changes in the parasite that could compromise the efficacy of anti-malarial drugs. These tools should be fast, cost-effective, sensitive and easy to perform. PCR–RFLP is a tool that has remarkable potential to detect the emerging mutations of candidate resistance markers.
The current study presents a molecular update on
pvmdr1 gene for more understanding about the possible recent selection of CQ-resistant markers. All of our studied isolates from pre-treatment samples were obtained from patients that were successfully treated with CQ and the result of molecular analysis showed a high proportion of Y976/1076
L single mutant haplotype (with 96.2% frequency). The earlier molecular study in Hormozgan, Iran showed that most isolates (97/100, 97%) carried single mutant haplotype (Y976/1076
L) [
21], as in the present study (101/105, 96.2%). Compared to
P. vivax isolates collected in Hormozgan during 2007–2013 [
21], there was no evidence for selection of mutants due to CQ pressure. In accordance with these findings, two previous studies from neighbouring Afghanistan [
22] and Pakistan [
23] revealed that all the isolates were wild type at 976 position and almost all (100% in Afghanistan and 98% in Pakistan) carried the F1076L mutant allele. The dominance of single mutant haplotype in CQ-sensitive isolates in this investigation that is in accordance with previous studies from Iran or bordering countries [
21‐
24] could reflect the fact that
P. vivax resistance to CQ has not emerged. Some reports suggested the hypothesis of the two-step mutational trajectory in
pvmdr1 gene, with the increase of F1076L mutation followed by Y976F which may lead to CQ resistance [
8,
25]. The occurrence of F1076L mutation in almost all the analysed isolates does suggest that resistant genotype will continue to emerge in this region before the appearance of the resistance phenotype. This could potentially provide an early warning that resistance to CQ is possibly emerging. However, the exact role of F1076L mutation in CQ resistance and its clinical significance needs to be determined.
The Y976F mutation in
pvmdr1 gene has been identified as a possible genetic marker of resistance to CQ in Southeast of Asia and the Western Pacific. This mutation almost reached fixation in high-level CQ-resistant
P. vivax foci including Indonesia and PNG [
11,
26]. Conversely, in Thailand with low-grade CQ resistance, prevalence of the Y976
F mutant allele is at low levels [
11,
26]. Additionally, in Korea and India with some rare cases of CQ resistance [
27‐
30], the Y976F mutant was absent in the case of Korea [
9,
26,
31] or observed with very low frequency in India [
32,
33]. In the case of Eastern Mediterranean regions, where CQ treatment is generally effective, the Y976F mutation was not detected in
P. vivax isolates from several countries including Iran [
21], Pakistan [
23] and Afghanistan [
22]. Since CQ resistance was also observed in isolates with wild type Y976F [
11], this variation in parasite population in different endemic regions may reflect the geographical characteristics of Y976F mutation rather than an association with CQ resistance. This theory has also been suggested previously [
21,
34]. Further investigations are needed to assess the role of Y976F mutation in CQ therapeutic failure.
There may be some possible limitations in this study that could be addressed in future research. First, in this study it was not possible to follow up patients for assessment of susceptibility to CQ because all of the analysed samples were collected from Pakistani travellers who returned to their country after receiving treatment. Second, for PCR–RFLP analysis of mutation at codon 976, it was suggested to use AclI restriction enzyme with the specificity to cut only the Y976F mutant allele (reviewer suggestion). However, due to the limitation of this study, the available enzyme (MboII) was used for mutation analysis of Y976F position. In addition, the relevance of other candidate markers for CQ resistance, including pvmdr1 copy number variation, pvcrt-o gene expression and pvcrt-o genetic variation cannot be ruled out. Nevertheless, due to the financial issues, the assessment was not possible in the present study. This demands further assessment of the drug resistance markers complemented with in vivo and ex vivo therapeutic efficacy studies to confirm their role in the CQ treatment failure.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.