The first TRAC study was a three year project across 15 sites in both Asia and Africa. The results of the study, published in the New England Journal of Medicine in July 2014, confirmed that artemisinin resistant falciparum malaria was firmly established in Western Cambodia, Thailand, Vietnam, Eastern Myanmar and Northern Cambodia. 

Since the publication of this study, artemisinin resistance has further extended into Central Myanmar, Southern Laos and Northeastern Cambodia. TRAC II explores if the resistant artemisinin phenotype has spread further westward into Myanmar, Bangladesh and India, and to what extent resistance to partner drugs has emerged in South and Southeast Asia. This is assessed by clinical studies looking in great detail at parasite clearance parameters and treatment efficacy, as well by genetic and transcriptomic methods and in-vitro sensitivity assays. The study covers 17 sites in eight different countries (16 in Asia, 1 in Sub-Saharan Africa). The first patient was recruited in August 2015. More than 1,100 subjects have been recruited in 8 countries (Bangladesh, Cambodia, Democratic Republic of Congo (DRC), India, Lao PDR, Myanmar, Thailand and Viet Nam). The preliminary analyses are being communicated at international conferences and have been shared with representatives of the national malaria control programs and the World Health Organization.

Artemisinin drug resistance has selected for concomitant resistance to the partner drug in ACTs, in some areas resulting in high failure rates with artemisinin combination therapies (ACTs) – the current frontline treatment against falciparum malaria.   

Treatment failures after artemisinin combination therapies are likely to become more widespread in Southeast Asia. Currently ACT failure rates over 30% with the ACTs dihydroartemisinin-piperaquine and mefloquine-artesunate have been reported from western and northern Cambodia and the Myanmar-Thailand border areas. The failure of ACTs against malaria infection severely threatens malaria control and elimination efforts, and will accelerate the spread and emergence of resistance.

The imminent danger of untreatable falciparum malaria in the region urgently requires alternative treatment options. This will have to use existing drugs, since new compounds are years away. In TRAC II, partner drugs with likely opposing resistance mechanisms are combined into Triple Artemisinin-based Combination Therapies (TACTs). The TACTs that are studied are dihydroartemisinin-piperaquine with mefloquine and artemether-lumefantrine with amodiaquine. The project examines the safety, tolerability and efficacy of these TACT combinations, and study the pharmacokinetic and dynamic drug interactions.  

In addition, TRAC II studies a recent developed synthetic trioxolane antimalarial arterolane, which is marketed in combination with piperaquine. The efficacy of this new combination is tested in areas of artemisinin and partner drug resistance.

Novel vector control measures are urgently needed to aid artemisinin resistance containment efforts in Southeast Asia. This is due in part to the outdoor and early evening blood feeding behaviors of Southeast Asian mosquitoes that transmit malaria, which renders bednets and indoor residual spraying with insecticides less effective. Treating people with ivermectin can make their blood lethal to mosquitoes, and thus could be an effective control measure to target outdoor-feeding malaria vectors. Ivermectin mass drug administration (MDA) shows promise as a vector control tool in West Africa as it reduces wild malaria vector survival up to one week and suppresses transmission for two weeks. Ivermectin could be combined with antimalarial drugs currently used in MDA format in Southeast Asia. These multi-drug MDAs would clear asymptomatic malaria cases from the human population while simultaneously suppressing transmission by local mosquitoes preventing new malaria cases. A sequential clinical trial to assess the safety, tolerability, pharmacokinetic interaction, and mosquito-lethal efficacy of ivermectin, dihydroartemisinin-piperaquine, and primaquine was completed in 2016. The results of this study are expected to be published by the middle of 2019.

1. Efficacy, safety, tolerability assessments

TRAC II is the first study to trial the use of triple artemisinin combination therapies (TACTs) and will focus on the safety and efficacy of these treatments.

The teams run three randomised trials with a 42 day follow-up:

• Three days of dihydroartemisinin-piperaquine (ACT) versus three days of dihydroartemisinin-piperaquine with mefloquine (TACT)

• Three days of artesunate-mefloquine (ACT) versus three days of dihydroartemisinin-piperaquine with mefloquine (TACT)

• Three days of artemether-lumefantrine (ACT) versus three days of artemether-lumefantrine with piperaquine (TACT)

Efficacy estimates will be based on microscopy and will be PCR-corrected. Microscopy-based parasite clearance estimates are obtained with the WWARN Parasite Clearance Estimator.

Safety related assessments include measurements of:

• Biochemical markers of renal and hepatic toxicity,

• Full blood counts with differential white blood cell counts

• Electrocardiographic (ECG) recordings

A further randomised trial will be started in 2017 in Kenya in collaboration with the Kenya Medical Research Institute (KEMRI) looking at safety and efficacy of the synthetic trioxalane antimalarial arterolane in combination with piperaquine:

• Three days of arterolane-piperaquine versus three days artemether-lumefantrine (ACT) versus three days dihydroartemisinin-piperaquine with mefloquine (TACT)

Additional measurements will be performed to assess partner drug pharmacokinetics and pharmacodynamics, and to eliminate inadequate drug absorption as a cause of any eventual treatment failures. 

2. Vector Control

TRAC II is the first study to trial the use of ivermectin treatment as a vector control tool in Southeast Asia.

The team has run a sequential trial in healthy volunteers at MORU:

• Ivermectin (400 μg/kg) single dose

• Ivermectin with primaquine (30 mg) single dose

• Ivermectin with dihydroartemisinin-piperaquine (120/960 mg) single dose

• Ivermectin with dihydroartemisinin-piperaquine and primaquine single dose

Potential drug-drug interactions are currently being assessed. Efficacy data is based on mosquito lethality for Anopheles dirus and Anopheles minimus performed at AFRIMS.

Safety and tolerability related assessments include measurements of:

• Biochemical markers of renal and hepatic toxicity,

• Electrocardiographic (ECG) recordings

• Symptoms questionnaires

3.  Demand factors

4. Parasite biology and phenotypes

Advanced investigations of parasite biology and phenotypes include analysis of the parasites obtained through the clinical TRACII studies:

• Parasite genotyping including whole genome sequencing, markers of resistance (kelch13 and markers for partner drug resistance), and barcoding for genetic epidemiology

• Genomics to investigate the selection and emergence of drug resistance mutations

• Transcriptomics to elucidate further the biological mechanisms of drug resistance

• Ex vivo and/or in vitro drug susceptibility assays and estimation of parasite clearance by molecular methods to define parasite phenotypes

TRAC II, the extension of the TRAC project, was funded by a grant from the UK Government Department for International Development (DFID).

The trial is led by Prof Arjen Dondorp (arjen@tropmedres.ac)) and Prof Nicholas White and coordinated by Dr Rob van der Pluijm (rob@tropmedres.ac). A large team of local investigators will be pivotal for the success of the studies. The trial will be overseen by a Steering Committee and a Data and Safety Monitoring Board. Clinical trial, laboratory, data management, statistical, logistical and administrative support will be provided from Mahidol-Oxford Research Unit in Bangkok. A large group of international collaborators will contribute to the different embedded scientific projects. WWARN researchers, under the guidance of Dr Mehul Dhorda, are responsible for quality assurance of specimen collection and processing, as well as microscopy.

• WWARN
• Mahidol University
• Oxford University
• London School of Hygiene and Tropical Medicine
• Wellcome Trust Sanger Institute
• National Institutes of Health
• Nanyang University, Singapore
• Institut Pasteur
• Armed Forces Research Institute of Medical Sciences

To learn more or optimise your tools for reporting artemisinin drug resistance, view our kelch markers toolkit for minimal criteria in reporting Plasmodium falciparum kelch13 (pfkelch13) markers.

• Imwong M et al. The spread of artemisinin-resistant Plasmodium falciparum in the Greater Mekong subregion: a molecular epidemiology observational study. Lancet Infect Dis. 2017 May;17(5):491-497. Epub 2017 Feb 2. doi: 10.1016/S1473-3099(17)30048-8. 

• Mukherjee A, et al. Artemisinin resistance without pfkelch13 mutations in Plasmodium falciparum isolates from Cambodia. Malar J. 2017 May 12;16(1):195. PMID: 28494763. DOI: 10.1186/s12936-017-1845-5
• Ataide R, et al. Host immunity and the assessment of emerging artemisinin resistance in malaria: a multinational cohort study. Proc Natl Acad Sci U S A. 2017 Mar 28;114(13):3515-3520. DOI: 10.1073/pnas.1615875114
• Srimuang K, et al.; Tracking Resistance to Artemisinin Collaboration. Analysis of anti-malarial resistance markers in pfmdr1 and pfcrt across Southeast Asia in the Tracking Resistance to Artemisinin Collaboration. Malar J. 2016 Nov 8;15(1):541. DOI: 10.1186/s12936-016-1598-6
• Grist EP, et al. Optimal health and disease management using spatial uncertainty: a geographic characterization of emergent artemisinin-resistant Plasmodium falciparum distributions in Southeast Asia. Int J Health Geogr. 2016 Oct 24;15(1):37. DOI: 10.1186/s12942-016-0064-6
• Charlwood JD, et al. Effects of the spatial repellent metofluthrin on landing rates of outdoor biting  anophelines in Cambodia, Southeast Asia. Med Vet Entomol. 2016 Jun;30(2):229-34. doi: 10.1111/mve.12168. Epub 2016 Mar 15. PubMed PMID: 26991881. DOI: 10.1111/mve.12168
• WWARN Gametocyte Study Group. Gametocyte carriage in uncomplicated Plasmodium falciparum malaria following treatment with artemisinin combination therapy: a systematic review and meta-analysis of individual patient data. BMC Med. 2016 May 24;14:79.  DOI: 10.1186/s12916-016-0621-7
• Tun KM, et al. Parasite clearance rates in Upper Myanmar indicate a distinctive artemisinin resistance phenotype: a therapeutic efficacy study. Malar J. 2016 Mar 31; 15(1):185. doi:  10.1186/s12936-016-1240-7
• MalariaGEN Plasmodium falciparum Community Project. Genomic epidemiology of artemisinin resistant malaria. Elife. 2016 Mar 4; 5. pii: e08714. DOI: 10.7554/eLife.08714
• WWARN Parasite Clearance Study Group. Baseline data of parasite clearance in patients with falciparum malaria treated with an artemisinin derivative: an individual patient data meta-analysis. Malar J. 2015 Sep 22; 14:359. DOI: 10.1186/s12936-015-0874-1
• Tun KM, et al. Spread of artemisinin-resistant Plasmodium falciparum in Myanmar: a cross-sectional survey of the K13 molecular marker. Lancet Infect Dis. 2015 Feb 18. DOI: 10.1016/S1473-3099(15)70032-0
• Ashley EA, et al. ‘Spread of Artemisinin Resistance in Plasmodium falciparum Malaria’ New England Journal of Medicine (2014). DOI: 10.1056/NEJMoa1314981
• Miotto O, Amato R, et al. Genetic architecture of artemisinin-resistant Plasmodium falciparum. Nat Genet. 2015 Jan 19. doi: 10.1038/ng.3189.
• Mok S, Ashley EA, et al. Population transcriptomics of human malaria parasites reveals the  mechanism of artemisinin resistance. Science. 2014 Dec 11. pii: 1260403 
• Das D, Cheah PY, et al. Participants' perceptions and understanding of a malaria clinical trial in Bangladesh. Malar J. 2014 Jun 4;13(1):217.
• Lim P, Dek D, et al.  Ex vivo susceptibility of Plasmodium falciparum to antimalarial drugs in western, northern, and eastern Cambodia, 2011-2012: association with molecular markers. Antimicrob Agents Chemother. 2013; 57: 5277-83.
• Guyant P, Canavati SE, et al.  Malaria and the mobile and migrant population in Cambodia: a population movement framework to inform strategies for malaria control and elimination. Malar J. 2015 Jun 20;14:252. doi: 10.1186/s12936-015-0773-5. PubMed PMID: 26088924
• Yeung S, Lawford HL, et al. Quality of antimalarials at the epicenter of antimalarial drug resistance: results from an overt and mystery client survey in Cambodia. Am J Trop Med Hyg.2015 Jun;92(6 Suppl):39-50. doi: 10.4269/ajtmh.14-0391. Epub 2015 Apr 20. PubMed PMID: 25897063; PubMed Central PMCID: PMC4455075.
• Charlwood JD, Tomás EV, et al. Evidence of an 'invitation' effect in feeding sylvatic Stegomyia albopicta from Cambodia. Parasit Vectors. 2014 Jul 11;7:324. doi: 10.1186/1756-3305-7-324. PubMed PMID: 25015104; PubMed Central PMCID: PMC4230241.