Comment procéder pour traquer les marqueurs génétiques de résistance aux artemisinines et autres nouvelles molécules antipaludiques ? - Conférence de la 5e édition du Cours international « Atelier Paludisme » - Carol HOPKINS SIBLEY - University of Washington Seattle, USA - sibley@u.washington.edu

1. ASSURING
ASSURING
EFFECTIVE ANTIMALARIAL TREATMENT:
EFFECTIVE ANTIMALARIAL TREATMENT:
A PLAN FOR MOVING FORWARD
A PLAN FOR MOVING FORWARD
CAROL HOPKINS SIBLEY
CAROL HOPKINS SIBLEY
ATELIER PALUDISME
ATELIER PALUDISME
MADAGASGAR
MADAGASGAR
MARCH 19, 2007
MARCH 19, 2007

2. MALARIA MORTALITY IN AFRICA
MALARIA MORTALITY IN AFRICA
HAS INCREASED
HAS INCREASED

3. WHAT ARE THE PRACTICAL CONSEQUENCES?
WHAT ARE THE PRACTICAL CONSEQUENCES?
ESTIMATED ALL- CAUSE CHILD MORTALITY
ESTIMATED ALL- CAUSE CHILD MORTALITY
SNOW, TRAPE AND MARSH, 2001
SNOW, TRAPE AND MARSH, 2001

4. ESTIMATED MALARIA MORTALITY
ESTIMATED MALARIA MORTALITY

5. WHY THE OPPOSITE TRENDS ?
WHY THE OPPOSITE TRENDS ?
MALARIA
ALL CAUSE

6. RESISTANCE TO THREE
RESISTANCE TO THREE
COMMON
COMMON
INEXPENSIVE
INEXPENSIVE
WELL TOLERATED
WELL TOLERATED
DRUGS
DRUGS
HAS EVOLVED
HAS EVOLVED
•• CHLOROQUINE
CHLOROQUINE
•• SULFADOXINE-PYRIMETHAMINE
SULFADOXINE-PYRIMETHAMINE
•• MEFLOQUINE
MEFLOQUINE

7. WHO SUMMARY
WHO SUMMARY
WHO/RBM
WHO/RBM
REPORT
REPORT
PASCAL
PASCAL
RINGWALD
RINGWALD
2004
2004

8. 2005 MAP OF RESISTANCE
2005 MAP OF RESISTANCE
3 CURRENT DRUGS
3 CURRENT DRUGS

9. HOW DO WE DEFINE DRUG RESISTANCE
HOW DO WE DEFINE DRUG RESISTANCE
•• IN VIVO
IN VIVO
DOES A PROPERLY TREATED PATIENT RECOVER?
DOES A PROPERLY TREATED PATIENT RECOVER?
•• IN VITRO
IN VITRO
HOW SENSITIVE IS A PARASITE ISOLATE
HOW SENSITIVE IS A PARASITE ISOLATE
TO DRUG ?
TO DRUG ?
•• MOLECULAR
MOLECULAR
ARE MUTATIONS ASSOCIATED WITH
ARE MUTATIONS ASSOCIATED WITH
RESISTANCE COMMON IN THE REGION?
RESISTANCE COMMON IN THE REGION?
•• PHARMACOKINETICS
PHARMACOKINETICS
DID THE PATIENT HAVE A CORRECT LEVEL OF
DID THE PATIENT HAVE A CORRECT LEVEL OF
DRUG IN THE BLOOD?
DRUG IN THE BLOOD?

10. HOW DO WE MONITOR
HOW DO WE MONITOR
DRUG EFFICACY?
DRUG EFFICACY?
PATIENT RESPONSE TO TREATMENT
PATIENT RESPONSE TO TREATMENT
FOLLOW UP 28 DAYS ++
FOLLOW UP 28 DAYS ++
SYMPTOMS AND PARASITES GONE
ACPR SYMPTOMS AND PARASITES GONE
ALL 28 DAYS
ALL 28 DAYS
SYMPTOMS REAPPEAR
SYMPTOMS REAPPEAR
WITHIN 3 DAYS
ETF WITHIN 3 DAYS
WITHIN 28 DAYS
LTF WITHIN 28 DAYS
LPF PARASITES ONLY REAPPEAR
PARASITES ONLY REAPPEAR
WITHIN 28 DAYS
WITHIN 28 DAYS

11. WHAT FACTORS INFLUENCE THE
WHAT FACTORS INFLUENCE THE
CLINICAL RESPONSE?
CLINICAL RESPONSE?
•• PRIOR EXPOSURE
PRIOR EXPOSURE
•• OTHER INFECTIONS
OTHER INFECTIONS
•• NUTRITIONAL STATUS
NUTRITIONAL STATUS
•• POSSIBILITY OF REINFECTION
POSSIBILITY OF REINFECTION
•• OTHER DRUG USE
OTHER DRUG USE

12. HOW IS THIS INFORMATION USED?
HOW IS THIS INFORMATION USED?
WHO GUIDELINES- 2006
WHO GUIDELINES- 2006
>15% CLINICAL/PARASTIOLOGICAL
>15% CLINICAL/PARASTIOLOGICAL
FAILURES-
FAILURES-
CHANGE TO NEW DRUG
CHANGE TO NEW DRUG

13. WHAT HAVE WE LEARNED ABOUT THE
WHAT HAVE WE LEARNED ABOUT THE
EVOLUTION OF DRUG RESISTANCE?
EVOLUTION OF DRUG RESISTANCE?
••TWO IMPORTANT PHASES OF RESISTANCE
TWO IMPORTANT PHASES OF RESISTANCE
•• SELECTION OF RESISTANCE
SELECTION OF RESISTANCE
•• PROPAGATION OF RESISTANCE
PROPAGATION OF RESISTANCE
FOCI OF CLINICAL RESISTANCE ARISE
RELATIVELY RARELY TO CQ AND SP

14. BUT RESISTANCE STRAINS CAN
BUT RESISTANCE STRAINS CAN
RAPIDLY PREDOMINATE
RAPIDLY PREDOMINATE

15. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1978
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

16. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1981
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
1978
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

17. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1982
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

18. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1983
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
1978
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

19. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1984
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

20. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1985
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

21. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1986
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

22. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1987
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

23. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1988
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

24. FIRST REPORTS OF
FIRST REPORTS OF
CHLOROQUINE RESISTANCE IN AFRICA
CHLOROQUINE RESISTANCE IN AFRICA
1989
HUMAN
HUMAN
MIGRATION
MIGRATION
IS KEY
IS KEY
TO
TO
RESISTANCE
RESISTANCE
SPREAD
SPREAD
ADAPTED FROM
ADAPTED FROM
CHARMOT ET AL, 1991
CHARMOT ET AL, 1991

25. DATA SUMMARIES ARE BY COUNTRY
DATA SUMMARIES ARE BY COUNTRY

26. BUT …. RESISTANCE IS NOT UNIFORM
BUT …. RESISTANCE IS NOT UNIFORM
WITHIN COUNTRIES
WITHIN COUNTRIES

27. TREATMENT FAILURE = RESISTANCE?
TREATMENT FAILURE = RESISTANCE?
DOSE OF DRUG ADEQUATE?
DOSE OF DRUG ADEQUATE?
NO
NO YES
YES
RESISTANCE?
RESISTANCE?
MAY NOT
MAY NOT
BE
BE
RESISTANCE
RESISTANCE IN VITRO GENETIC
GENETIC
IN VITRO
RESPONSE
RESPONSE ANALYSIS
ANALYSIS
OF PARASITES
OF PARASITES OF PARASITE
OF PARASITE
TO DRUGS
TO DRUGS
HIGHER THAN MARKERS
MARKERS
HIGHER THAN OF DRUG
STANDARD?
STANDARD? OF DRUG
RESISTANCE?
RESISTANCE?

28. MEASUREMENT OF PARASITE DRUG SENSITIVITY
MEASUREMENT OF PARASITE DRUG SENSITIVITY
IN VITRO
IN VITRO
INFECTED BLOOD + PBS
AVOIDS MAJOR
CF11 column
HOST FACTORS:
IMMUNITY
NUTRITION
CALCULATE
DRUG RESPONSE
RESUSPEND IN MEDIUM AND
SERUM
PATIENT ISOLATE
A
B
C
MEASURE GROWTH
D
E
F
G
H
INCUBATE 37 O C
DRUG CONCENTRATION
24-36 H

29. DRUG RESPONSE OF FIELD SAMPLES
DRUG RESPONSE OF FIELD SAMPLES
SCREENED BY GROWTH IN VITRO
SCREENED BY GROWTH IN VITRO
120
110
100
RELAT IVE GROWT H
90
80
70 Y5D3
60 S108
50 S108N
40 S108N + N51I
30
F.S. 7 E4
20
10 F.S. C1
0
0 1E -9 1E -8 1E -7 1E -6 1E -5
[PYRIMETHAMINE
IC50 3.4 x 10-8 IC50 4 x 10-7 IC50 9 x 10-7

30. MOLECULAR MARKERS
MOLECULAR MARKERS
OF DRUG RESISTANCE
OF DRUG RESISTANCE
CQ
CQ Pfcrt
Pfcrt SNPs
SNPs
Pfmdr1
Pfmdr1 SNPs
SNPs
SP
SP Pfdhfr
Pfdhfr SNPs
SNPs
Pfdhps
Pfdhps SNPs
SNPs
MEF
MEF Pfmdr1
Pfmdr1 COPY
COPY
NUMBER
NUMBER

31. ONE GENE IS NECESSARY FOR CQ-R
ONE GENE IS NECESSARY FOR CQ-R
In P. falciparum
In P. falciparum
But probably is not sufficient!
But probably is not sufficient!

32. DHFR MUTATIONS THAT CONFER
DHFR MUTATIONS THAT CONFER
PYRIMETHAMINE RESISTANCE IN FIELD ISOLATES
PYRIMETHAMINE RESISTANCE IN FIELD ISOLATES
PYRS Asn Cys Ser Ile
51 59 Pf DHFR 108 164
PYRR Asn Cys ASN Ile
ILE Cys ASN Ile
ILE ARG ASN Ile
ILE ARG ASN LEU

33. MOLECULAR MARKERS CAN ASSESS
MOLECULAR MARKERS CAN ASSESS
PARASITE DRUG RESISTANCE
PARASITE DRUG RESISTANCE
DHFR
DHFR
AND
AND
DHPS
DHPS
ALLELES
ALLELES
TANZANIA
TANZANIA
2002-2004
2002-2004
TRIPLE MUTANT dhfr
TRIPLE MUTANT dhfr
DOUBLE MUTANT dhps
DOUBLE MUTANT dhps
Mugittu et al 2004

34. Pfmdr1 COPY NUMBER
Pfmdr1 COPY NUMBER
IS MARKER OF MEFLOQUINER
IS MARKER OF MEFLOQUINER
1.0
2.0
MQS
MQR 1.1
2.3
Wongsrichanalai C., 2005

35. STUDIES IN PATIENTS ARE
STUDIES IN PATIENTS ARE
EXPENSIVE
EXPENSIVE
AND
AND
TIME CONSUMING
TIME CONSUMING
KEY QUESTION:
KEY QUESTION:
MOLECULAR MARKERS
MOLECULAR MARKERS
OR
OR
IN VITRO ANALYSIS
IN VITRO ANALYSIS
GOOD SURROGATES
GOOD SURROGATES
TO PREDICT
TO PREDICT
CLINICAL TREATMENT FAILURE?
CLINICAL TREATMENT FAILURE?

36. MOLECULAR MARKERS CAN ASSESS
MOLECULAR MARKERS CAN ASSESS
PARASITE DRUG RESISTANCE
PARASITE DRUG RESISTANCE
DHFR
DHFR
TRIPLE MUTANT dhfr
DOUBLE MUTANT dhps AND
AND
DHPS
DHPS
ALLELES
ALLELES
TANZANIA
TANZANIA
2002-2004
2002-2004
CLINICAL FAILURE
Mugittu et al 2004

37. MOLECULAR MARKERS OF SP RESISTANCE
MOLECULAR MARKERS OF SP RESISTANCE
CORRLEATE WITH CLINICAL FAILURE
CORRLEATE WITH CLINICAL FAILURE
1.0
Observed-14
Observed-28
Observed-42
0.8 Fit-14
CLINICAL FAILURE
Fit-28
Fit-42
0.6
0.4
0.2
0
0 0.1 0.2 0.3 0.4 0.5 0.6
PREVALENCE OF "TRIPLE/DOUBLE"

38. HOW CAN WE FIT THIS TOGETHER?
HOW CAN WE FIT THIS TOGETHER?
EARLY WARNINGS OF CLINICAL FAILURE
100%
DATA FROM
PREVALENCE OF RESISTANT P[ARASITES (%)
90% ALEXIS NZILA
TRIPLE MUTANTS DHFR
EDWARD MBERU KAMAU
CAROL SIBLEY
X
ro
70%
vit
S
NT
in
CE
A
60%
UT
AN
EM
o
ST
50%
iv 50% 50%
IPL
v
SI
in
RE
TR
E
C
PM
%
N
A 30% 30%
X ST
SI
E
R 20% 20%
X /S
D
10% PM 10% 10%
90-93 93-95 95-97 97-99 00-02
UNTIL LATE 80s
PM/SD INTRODUCED KILIFI, KENYA

39. WHAT HAVE WE LEARNED?
WHAT HAVE WE LEARNED?
•• RESISTANCE ARISES RARELY, BUT
RESISTANCE ARISES RARELY, BUT
SPREADS RELATIVELY QUICKLY
SPREADS RELATIVELY QUICKLY
•• CLINICAL TREATMENT FAILURE IS THE LAST
CLINICAL TREATMENT FAILURE IS THE LAST
STEP IN A LONG SERIES OF CHANGES
STEP IN A LONG SERIES OF CHANGES
•• EARLY WARNING OF RESISTANCE
EARLY WARNING OF RESISTANCE
•• SLOWER TIME TO CLEAR PARASITES
SLOWER TIME TO CLEAR PARASITES
•• IN VITRO INCREASES IN IC50 VALUE
IN VITRO INCREASES IN IC50 VALUE
•• INCREASING PREVALENCE OF
INCREASING PREVALENCE OF
“RESISTANT” ALLELES
“RESISTANT” ALLELES

40. WHAT DATA ARE MISSING?
WHAT DATA ARE MISSING?
•• SURVEILLANCE SPOTTY
SURVEILLANCE SPOTTY
•• REPORTS LONG AFTER FACT
REPORTS LONG AFTER FACT
BUT THIS IS IMPROVING RAPIDLY

41. 1986
VERY LONG
VERY LONG
LAG
LAG
BETWEEN
BETWEEN
SEEING
SEEING
4-5 years RESISTANCE
RESISTANCE
6-7 years AND
AND
8 years CHANGING
CHANGING
DRUG
DRUG
POLICY
POLICY
Charmot et al 1991
NEED FAR BETTER COORDINATION AMONG GROUPS
NEED FAR BETTER COORDINATION AMONG GROUPS
INVOLVED IN RESISTANCE DETERMINATION
INVOLVED IN RESISTANCE DETERMINATION

42. WE HAVE ALWAYS PLAYED CATCH UP
WE HAVE ALWAYS PLAYED CATCH UP
FROM WHITE, 1999
AS DRUGS FAIL, WE CHRONICLE THE FAILURES

43. WE NEED COORDINATED, OPEN ACCESS
WE NEED COORDINATED, OPEN ACCESS
DATABASE FROM ALL ENDEMIC AREAS
DATABASE FROM ALL ENDEMIC AREAS
NEEDS TO CONNECT WITH ROUTINE
SURVEILLANCE

44. WHAT MUST WE DO NOW?
WHAT MUST WE DO NOW?
•• CONSOLIDATE RECENT DATA ON “OLD”
CONSOLIDATE RECENT DATA ON “OLD”
DRUGS
DRUGS
•• CREATE AND MAINTAIN AN OPEN ACCESS
CREATE AND MAINTAIN AN OPEN ACCESS
DATABASE OF RESISTANCE DATA
DATABASE OF RESISTANCE DATA
WORLDWIDE
WORLDWIDE
•• WHERE DID RESISTANCE ARISE?
WHERE DID RESISTANCE ARISE?
•• OVER WHAT ROUTES DID SPREAD OCCUR?
OVER WHAT ROUTES DID SPREAD OCCUR?
•• HOW DO SURROGATE MARKERS RELATE TO
HOW DO SURROGATE MARKERS RELATE TO
CLINICAL OUTCOMES?
CLINICAL OUTCOMES?

45. THINGS USED TO BE SIMPLE…
THINGS USED TO BE SIMPLE…
CHLOROQUINE
CHLOROQUINE
SULFADOXINE/PYRIMETHAMINE
SULFADOXINE/PYRIMETHAMINE
QUININE
QUININE
MEFLOQUINE
MEFLOQUINE
MEFLOQUINE/ARTESUNATE
MEFLOQUINE/ARTESUNATE

46. RESISTANCE TO OLD DRUGS….
RESISTANCE TO OLD DRUGS….
CHANGE TO COMBINATION THERAPY
CHANGE TO COMBINATION THERAPY
2003 2006

47. 2006 ACT ADOPTIONS
2006 ACT ADOPTIONS
Countries which need ACT policy
Countries which adopted ACT

48. MANY ACTs ARE IN USE OR IN TRIAL
MANY ACTs ARE IN USE OR IN TRIAL
•• ARTESUNATE-MEFLOQUINE
ARTESUNATE-MEFLOQUINE
•• ARTEMETHER-LUMEFANTRINE
ARTEMETHER-LUMEFANTRINE
•• ARTESUNATE-AMODIAQUINE
ARTESUNATE-AMODIAQUINE
•• DIHYDROARTEMISININ-PIPERAQUINE
DIHYDROARTEMISININ-PIPERAQUINE
•• CHLORPROGUANIL-DAPSONE-ARTESUNATE
CHLORPROGUANIL-DAPSONE-ARTESUNATE
•• ARTESUNATE- SULFADOXINE-PYRIMETHAMINE
ARTESUNATE- SULFADOXINE-PYRIMETHAMINE
AND…..
AND…..
•• CHLOROQUINE- SULFADOXINE-PYRIMETHAMINE
CHLOROQUINE- SULFADOXINE-PYRIMETHAMINE
•• AMODIAQUINE -- SULFADOXINE-PYRIMETHAMINE
AMODIAQUINE SULFADOXINE-PYRIMETHAMINE

49. ACTs CURRENTLY EFFECTIVE,
ACTs CURRENTLY EFFECTIVE,
BUT……..
BUT……..
HOW CAN WE SUSTAIN
HOW CAN WE SUSTAIN
MAXIMUM
MAXIMUM
USEFUL THERAPEUTIC LIFE
USEFUL THERAPEUTIC LIFE
OF ACTs?
OF ACTs?
HOW CAN WE
HOW CAN WE
STAY AHEAD OF THE
STAY AHEAD OF THE
EVOLUTIONARY CURVE?
EVOLUTIONARY CURVE?

50. NETWORK MUST BE PROSPECTIVE
NETWORK MUST BE PROSPECTIVE
•• CURRENT TOOLS ARE ADEQUATE
CURRENT TOOLS ARE ADEQUATE
•• MANY WELL PLACED SENTINAL SITES
MANY WELL PLACED SENTINAL SITES
•• REAL TIME REPORTING MORE COMMON
REAL TIME REPORTING MORE COMMON
•• NEW INITIATIVES WITH COMPLEMENTARY
NEW INITIATIVES WITH COMPLEMENTARY
OBJECTIVES
OBJECTIVES
•• GLOBAL FUND REQUIREMENTS
GLOBAL FUND REQUIREMENTS
•• ACT CONSORTIUM
ACT CONSORTIUM
•• IPTp
IPTp
•• IPTi
IPTi

51. WORLD ANTIMALARIAL
WORLD ANTIMALARIAL
RESISTANCE NETWORK
RESISTANCE NETWORK
CLINICAL
DRUG
EFFICACY
MOLECULAR
PHARMACO-
MARKERS
LOGICAL
OF
ASSESSMENT
RESISTANCE
IN VITRO
DRUG
ASSESSMENT

52. PHARMACOLOGICAL
PHARMACOLOGICAL
ASSESSMENT OF DRUGS
ASSESSMENT OF DRUGS
CLINICAL
CLINICAL
DRUG
DRUG
EFFICACY
EFFICACY
PHARMACO-
LOGICAL WHY DID THE PATIENT
WHY DID THE PATIENT
ASSESSMENT FAIL TREATMENT?
FAIL TREATMENT?
WAS THE DRUG LEVEL
WAS THE DRUG LEVEL
ADEQUATE?
ADEQUATE?

53. CLINICAL FAILURE
CLINICAL FAILURE
WITH ADEQUATE DRUG
WITH ADEQUATE DRUG
PRESUMPTIVE
PRESUMPTIVE
RESISTANT PARASITES
RESISTANT PARASITES
IN VITRO ANALYSIS
IN VITRO ANALYSIS

54. PATIENT ISOLATES WITH INCREASED
PATIENT ISOLATES WITH INCREASED
DRUG RESISTANCE IN VITRO
DRUG RESISTANCE IN VITRO
CANDIDATES FOR INTENSIVE GENETIC
CANDIDATES FOR INTENSIVE GENETIC
ANALYSIS
ANALYSIS
IDENTIFICATION OF LOCI ASSOCIATED
IDENTIFICATION OF LOCI ASSOCIATED
WITH RESISTANCE TO EACH
WITH RESISTANCE TO EACH
PARTNER IN ACT
PARTNER IN ACT

55. HOW TO MOVE TO
HOW TO MOVE TO
EVIDENCE BASED DRUG USE
EVIDENCE BASED DRUG USE
WE’RE HERE
WE NEED
TO MOVE
TO HERE
Don deSavigny and Fred Binka
Don deSavigny and Fred Binka

56. DRUG RESISTANCE IN VIVO
DRUG RESISTANCE IN VIVO