Article Text

Plasmodium falciparum resistance to sulfadoxine-pyrimethamine in Africa: a systematic analysis of national trends
  1. Floriano Amimo1,2,
  2. Ben Lambert3,
  3. Anthony Magit4,
  4. Jahit Sacarlal2,
  5. Masahiro Hashizume1,
  6. Kenji Shibuya1,5
  1. 1Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
  2. 2Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
  3. 3MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
  4. 4Human Research Protection Program, University of California San Diego School of Medicine, University of California System, San Diego, California, USA
  5. 5Institute for Population Health, King’s College London, London, UK
  1. Correspondence to Dr Floriano Amimo; florianoamimo{at}


Introduction The rising burden of drug resistance is a major challenge to the global fight against malaria. We estimated national Plasmodium falciparum resistance to sulfadoxine-pyrimethamine (SP) across Africa, from 2000 to 2020.

Methods We assembled molecular, clinical and endemicity data covering malaria-endemic African countries up to December 2018. Subsequently, we reconstructed georeferenced patient data, using pfdhps540E and pfdhps581G to measure mid-level and high-level SP resistance. Gaussian process regression was applied to model spatiotemporal standardised prevalence.

Results In eastern Africa, mid-level SP resistance increased by 64.0% (95% uncertainty interval, 30.7%–69.8%) in Tanzania, 55.4% (31.3%–65.2%) in Sudan, 45.7% (16.8%–54.3%) in Mozambique, 29.7% (10.0%–45.2%) in Kenya and 8.7% (1.4%–36.8%) in Malawi from 2000 to 2010. This was followed by a steady decline of 76.0% (39.6%–92.6%) in Sudan, 65.7% (25.5%–85.6%) in Kenya and 17.4% (2.6%–37.5%) in Tanzania from 2010 to 2020. In central Africa, the levels increased by 28.9% (7.2%–62.5%) in Equatorial Guinea and 85.3% (54.0%–95.9%) in the Congo from 2000 to 2020, while in the other countries remained largely unchanged. In western Africa, the levels have remained low from 2000 to 2020, except for Nigeria, with a reduction of 14.4% (0.7%–67.5%) and Mali, with an increase of 7.0% (0.8%–25.6%). High-level SP resistance increased by 5.5% (1.0%–20.0%) in Malawi, 4.7% (0.5%–25.4%) in Kenya and 2.0% (0.1%–39.2%) in Tanzania, from 2000 to 2020.

Conclusion Under the WHO protocols, SP is no longer effective for intermittent preventive treatment in pregnancy and infancy in most of eastern Africa and parts of central Africa. Strengthening health systems capacity to monitor drug resistance at subnational levels across the endemicity spectrum is critical to achieve the global target to end the epidemic.

  • health policy
  • malaria
  • epidemiology
  • maternal health
  • child health

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  • Handling editor Alberto L Garcia-Basteiro

  • Contributors FA conceived of and designed the research, prepared the data, conducted statistical analysis, drafted the manuscript, drafted the supplemental material of the manuscript, discussed the results and contributed to the revision of the final manuscript. BL supported statistical analysis, reviewed the manuscript, supported interpretation and policy contextualisation, and contributed to the revision of the final manuscript. JS supported data preparation, reviewed the manuscript, supported interpretation and policy contextualisation, and contributed to the revision of the final manuscript. AM, MH and KS reviewed the manuscript, supported the interpretation and policy contextualisation, and contributed to the revision of the final manuscript. All authors read and approved the final manuscript.

  • Funding This study was funded by Ministry of Education, Culture, Sports, Science and Technology of Japan.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon a reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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