L’efficacité contestée du recours aux agents de santé communautaires pour la prise en charge du paludisme : évaluation du programme burkinabé dans les districts de Kaya et de Zorgho

Contexte. Le paludisme provoque annuellement le décès d’environ 25 000 enfants de moins de cinq ans au Burkina Faso. Afin d’améliorer un accès rapide à des traitements efficaces, les autorités burkinabées ont introduit en 2010 la prise en charge du paludisme par les agents de santé communautaires (ASC). Alors que son efficacité a été démontrée dans des études contrôlées, très peu d’études ont évalué cette stratégie implantée dans des conditions naturelles et à l’échelle nationale. Objectif. L’objectif central de cette thèse est d’évaluer, dans des conditions réelles d’implantation, les effets du programme burkinabé de prise en charge communautaire du paludisme sur le recours aux soins des enfants fébriles. Les objectifs spécifiques sont : (1) de sonder les perceptions des ASC à l’égard du programme et explorer les facteurs contextuels susceptibles d’affecter leur performance ; (2) d’estimer le recours aux ASC par les enfants fébriles et identifier ses déterminants ; (3) de mesurer, auprès des enfants fébriles, le changement des pratiques de recours aux soins induit par l’introduction d’une intervention concomitante – la gratuité des soins dans les centres de santé. Méthodes. L’étude a été conduite dans deux districts sanitaires similaires, Kaya et Zorgho. Le devis d’évaluation combine des volets qualitatifs et quantitatifs. Des entrevues ont été menées avec tous les ASC de la zone à l’étude (N=27). Des enquêtes ont été répétées annuellement entre 2011 et 2013 auprès de 3002 ménages sélectionnés aléatoirement. Les pratiques de recours aux soins de tous les enfants de moins de cinq ans ayant connu un récent épisode de maladie ont été étudiées (N2011=707 ; N2012=787 ; N2013=831). Résultats. Les résultats montrent que le recours aux ASC est très modeste en comparaison de précédentes études réalisées dans des milieux contrôlés. Des obstacles liés à l’implantation du programme de prise en charge communautaire du paludisme ont été identifiés ainsi qu’un défaut de faisabilité dans les milieux urbains. Enfin, l’efficacité du programme communautaire a été négativement affectée par l’introduction de la gratuité dans les centres de santé. Conclusion. La prise en charge communautaire du paludisme rencontre au Burkina Faso des obstacles importants de faisabilité et d’implantation qui compromettent son efficacité potentielle pour réduire la mortalité infantile. Le manque de coordination entre le programme et des interventions locales concomitantes peut générer des effets néfastes et inattendus.

13C-2H correlation NMR spectroscopy studies of the in vivo transformations of natural products from Artemisia annua

13C-2H correlation NMR spectroscopy (13C-2H COSY) permits the identification of 13C and 2H nuclei which are connected to one another by a single chemical bond via the sizeable 1JCD coupling constant. The practical development of this technique is described using a 13C-2H COSY pulse sequence which is derived from the classical 13C-1H correlation experiment. An example is given of the application of 13C-2H COSY to the study of the biogenesis of natural products from the anti-malarial plant Artemisia annua, using a doubly-labelled precursor molecule. Although the biogenesis of artemisinin, the anti-malarial principle from this species, has been extensively studied over the past twenty years there is still no consensus as to the true biosynthetic route to this important natural product – indeed, some published experimental results are directly contradictory. One possible reason for this confusion may be the ease with which some of the metabolites from A. annua undergo spontaneous autoxidation, as exemplified by our recent in vitro studies of the spontaneous autoxidation of dihydroartemisinic acid, and the application of 13C-2H COSY to this biosynthetic problem has been important in helping to mitigate against such processes. In this in vivo application of 13C-2H COSY, [15-13C2H3]-dihydroartemisinic acid (the doubly-labelled analogue of the natural product from this species which was obtained through synthesis) was fed to A. annua plants and was shown to be converted into several natural products which have been described previously, including artemisinin. It is proposed that all of these transformations occurred via a tertiary hydroperoxide intermediate, which is derived from dihyroartemisinic acid. This intermediate was observed directly in this feeding experiment by the 13C-2H COSY technique; its observation by more traditional procedures (e.g., chromatographic separation, followed by spectroscopic analysis of the purified product) would have been difficult owing to the instability of the hydroperoxide group (as had been established previously by our in vitro studies of the spontaneous autoxidation of dihydroartemisinic acid). This same hydroperoxide has been reported as the initial product of the spontaneous autoxidation of dihydroartemisinic acid in our previous in vitro studies. Its observation in this feeding experiment by the 13C-2H COSY technique, a procedure which requires the minimum of sample manipulation in order to achieve a reliable identification of metabolites (based on both 13C and 2H chemical shifts at the 15-position), provides the best possible evidence for its status as a genuine biosynthetic intermediate, rather than merely as an artifact of the experimental procedure.

Synthesis of labelled dihydroartemisinic acid

[15-(CH3)-C-13-H-2]-Dihydroartemisinic acid (2a), [15-(CH3)-H-2]-dihydroartemisinic acid (2b) and [15-(CH3)-C-13]-dihydroartemisinic acid (2c) have been obtained in good yield and high isotopic enrichment by a reconstructive synthesis from artemisinin. These labelled compounds were designed to be used in biosynthetic experiments to determine the origins of artemisinin and other sesquiterpene natural products from Artemisia annua. (C) 2003 Elsevier Ltd. All rights reserved.

In vivo transformations of artemisinic acid in Artemisia annua plants

Artemisinic acid labeled with both C-13 and H-2 at the 15-position has been fed to intact plants of Artemisia annua via the cut stem, and its in vivo transformations studied by 1D- and 2D-NMR spectroscopy. Seven labeled metabolites have been isolated, all of which are known as natural products from this species. The transformations of artemisinic acid-as observed both for a group of plants, which was kept alive by hydroponic administration of water and for a group, which was allowed to die by desiccation-closely paralleled those, which have been recently described for its 11,13-dihydro analog, dihydroartemisinic acid. It seems likely therefore that similar mechanisms, involving spontaneous autoxidation of the Delta(4,5) double bond in both artemisinic acid and dihydroartemisinic acid and subsequent rearrangements of the resultant allylic hydroperoxides, may be involved in the biological transformations, which are undergone by both compounds. All of the sesquiterpene metabolites, which were obtained from in vivo transformations of artemisinic acid retained their unsaturation at the 11,13-position, and there was no evidence for conversion into any 11,13-dihydro metabolite, including artemisinin, the antimalarial drug, which is produced by A. annua. This observation led to the proposal of a unified biosynthetic scheme, which accounts for the biogenesis of many of the amorphane and cadinane sesquiterpenes that have been isolated as natural products from A. annua. In this scheme, there is a bifurcation in the biosynthetic pathway starting from amorpha-4,11-diene leading to either artemisinic acid or dihydroartemisinic acid; these two committed precursors are then, respectively, the parents for the two large families of highly oxygenated 11,13-dehydro and 11,13-dihydro sesquiterpene metabolites, which are known from this species. (C) 2007 Elsevier Ltd. All rights reserved.

In vivo transformations of dihydro-epi-deoxyarteannuin B in Artemisia annua plants

[15-(CH3)-C-13-H-2]-dihydro-epi-deoxyarteannuin B (4a) has been fed to intact Artemisia annua plants via the root and three labeled metabolites (17a-19a) have been identified by 1D- and 2D-NMR spectroscopies. The in vivo transformations of 4a in A. annua are proposed to involve enzymatically-mediated processes in addition to possible spontaneous autoxidation. In the hypothetical spontaneous autoxidation pathway, the tri-substituted double bond in 4a appears to have undergone 'ene-type' reaction with oxygen to form an allylic hydroperoxide, which subsequently rearranges to the allylic hydroxyl group in the metabolite 3 alpha-hydroxy-dihydro-epi-deoxyarteannuin B (17a). In the enzymatically-mediated pathways, compound 17a has then been converted to its acetyl derivative, 3 alpha-acetoxy-dihydro-epi-deoxyarteannuin B (18a), while oxidation of 4a at the 'unactivated' 9-position has yielded 9 beta-hydroxy-dihydro-epi-deoxyarteannuin B (19a). Although all of the natural products artemisinin ( 1), arteannuin K ( 7), arteannuin L ( 8), and arteannuin M ( 9) have been suggested previously as hypothetical metabolites from dihydro-epi-deoxyarteannuin B in A. annua, none were isolated in labeled form in this study. It is argued that the nature of the transformations undergone by compound 4a are more consistent with a degradative metabolism, designed to eliminate this compound from the plant, rather than with a role as a late precursor in the biosynthesis of artemisinin or other natural products from A. annua. (C) 2007 Elsevier Ltd. All rights reserved.

Proteomic analysis of the medicinal plant Artemisia annua: data from leaf and trichome extracts

This article contains raw and processed data related to research published by Bryant et al. [1]. Data was obtained by MS-based proteomics, analysing trichome-enriched, trichome-depleted and whole leaf samples taken from the medicinal plant Artemisia annua and searching the acquired MS/MS data against a recently published contig database [2] and other genomic and proteomic sequence databases for comparison. The processed data shows that an order-of-magnitude more proteins have been identified from trichome-enriched Artemisia annua samples in comparison to previously published data. Proteins known to have a role in the biosynthesis of artemisinin and other highly abundant proteins were found which imply additional enzymatically driven processes occurring within the trichomes that are significant for the biosynthesis of artemisinin.

Effectiveness of artemether-lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania : an open label prospective study

Background: Home-management of malaria (HMM) strategy improves early access of anti-malarial medicines to high-risk groups in remote areas of sub-Saharan Africa. However, limited data are available on the effectiveness of using artemisinin-based combination therapy (ACT) within the HMM strategy. The aim of this study was to assess the effectiveness of artemether-lumefantrine (AL), presently the most favoured ACT in Africa, in under-five children with uncomplicated Plasmodium falciparum malaria in Tanzania, when provided by community health workers (CHWs) and administered unsupervised by parents or guardians at home. Methods: An open label, single arm prospective study was conducted in two rural villages with high malaria transmission in Kibaha District, Tanzania. Children presenting to CHWs with uncomplicated fever and a positive rapid malaria diagnostic test (RDT) were provisionally enrolled and provided AL for unsupervised treatment at home. Patients with microscopy confirmed P. falciparum parasitaemia were definitely enrolled and reviewed weekly by the CHWs during 42 days. Primary outcome measure was PCR corrected parasitological cure rate by day 42, as estimated by Kaplan-Meier survival analysis. This trial is registered with ClinicalTrials.gov, number NCT00454961. Results: A total of 244 febrile children were enrolled between March-August 2007. Two patients were lost to follow up on day 14, and one patient withdrew consent on day 21. Some 141/241 (58.5%) patients had recurrent infection during follow-up, of whom 14 had recrudescence. The PCR corrected cure rate by day 42 was 93.0% (95% CI 88.3%-95.9%). The median lumefantrine concentration was statistically significantly lower in patients with recrudescence (97 ng/mL [IQR 0-234]; n = 10) compared with reinfections (205 ng/mL [114-390]; n = 92), or no parasite reappearance (217 [121-374] ng/mL; n = 70; p <= 0.046). Conclusions: Provision of AL by CHWs for unsupervised malaria treatment at home was highly effective, which provides evidence base for scaling-up implementation of HMM with AL in Tanzania.

Avaliação da atividade antimalárica e citotóxica de plantas medicinais dos Biomas Caatinga e Amazônico

Resistance of Plasmodium falciparum to the usual antimalarials, as well as their adverse effects and high cost, has led to the search of new drugs against malaria. Several of these have been developed from medicinal plants based on ethnopharmacology, including the most widely used antimalarials today: quinine and artemisinin. In the present study schizonticide activity of extracts and fractions of a number of medicinal plants from the Caatinga and Amazon biomes were assessed based on ethnopharmacological and chemosystematic information. These included Ximenia americana, Maytenus rigida, Sideroxylon obtusifolium, Stryphnodendro coriaceum, Bowdichia virgiliodes, Schinopis brasiliensis and Picrolemma sprucei, the last, an Amazon species. Antimalarial tests of blood schizonticides were conducted in Swiss mice infected with P. berghei and in vitro against P. falciparum. In vitro cytotoxicity studies were carried out using HeLa, CHO, 3T3, Raw and HEPG2 cell lines. Except for X. americana, all species exhibited in vivo or in vitro antimalarial activity, inhibiting parasitic growth by up to 79%. Extracts exhibited moderate toxicity with dosedependent kinetics. In this sense, ethnopharmacological and chemosystematic approaches were shown to be useful and promising tools in the search of new drugs. These findings represent a significant contribution to scientific knowledge of the antimalarial potential of Brazilian flora, thereby opening perspectives for the development of new antimalarials

Effect of Artemisia annua L. leaves essential oil and ethanol extract on behavioral assays

Artemisia annua tem sido utilizada tradicionalmente para o tratamento de malária e febre na China devido à presença do princípio ativo, artemisinina. O presente trabalho avaliou a atividade central de do óleo essencial obtido por hidrodestilação e do extrato etanólico bruto de folhas frescas de A. annua em modelo in vivo como parte de um screening farmacológico dessa espécie. Sono induzido por pentobarbital, nado forçado e o ensaio de campo aberto são modelos de estudo conhecidos para o estudo de fármacos sobre depressão induzida. A administração do óleo essencial ou extrato bruto etanólico de A. annua aumentaram o tempo de imobilidade no teste do nado forçado. Por outro lado, diminuíram outros parâmetros no campo aberto, como ambulação, exploração, o ato de lamber as patas ou se lamber. Ambos produtos aumentaram o tempo de sono induzido por pentobarbital, com o óleo essencial apresentando um efeito superior ao do extrato. Pela análise dos resultados, é possível sugerir que tanto o extrato bem como o óleo essencial podem atuar como depressores do Sistema Nervoso Central (SNC).

Genotoxicity assessment of the antimalarial compound artesunate in somatic cells of mice

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

In vitro activity of Artemisia annua L (Asteraceae) extracts against Rhipicephalus (Boophilus) microplus

A atividade de extratos vegetais sobre parasitas pode indicar grupos de substâncias de uso potencial no controle de Rhipicephalus (Boophilus) microplus. O objetivo do presente estudo foi investigar a ação in vitro de extratos de Artemisia annua sobre esta espécie. A concentração das lactonas sesquiterpênicas artemisinina e deoxiartemisinina presentes nos extratos vegetais, foi quantificada via cromatografia líquida de alta eficiência. Quatro extratos produzidos a partir do extrato bruto concentrado (EBC) foram avaliados sobre larvas pela metodologia do papel impregnado, com leitura após 24 horas de incubação. As fêmeas ingurgitadas foram imersas por cinco minutos no EBC e nos seus quatro extratos derivados, e incubadas para posterior análise dos parâmetros biológicos. Os extratos não tiveram eficácia sobre as larvas nas concentrações avaliadas (de 3,1 a 50 mg.mL-1). O EBC apresentou melhor eficácia sobre as fêmeas ingurgitadas (CE 50 de 130,6 mg.mL-1 e CE 90 de 302,9 mg.mL-1) que os extratos derivados. Esses resultados tendem a confirmar que a ação da artemisinina sobre as fêmeas ingurgitadas de R. (B.) microplus estaria condicionada à sua ingestão através do sangue. Nesse caso, os métodos in vitro seriam inadequados para a efetiva avaliação da ação de A. annua R.(B.) microplus.

Carbon isotope composition and leaf anatomy as a tool to characterize the photosynthetic mechanism of Artemisia annua L.

Leaves of Artemisia annua L. are a plentiful source of artemisinin, a drug with proven effectiveness against malaria. The aim of this study was to classify the photosynthetic mechanism of A. annua through studies of the carbon isotope composition (δ 13C) and the leaf anatomy. A. annua presented a δ 13C value of - 31.76 ± 0.07, which characterizes the plants as a typical species of the C3 photosynthethic mechanism, considering that the average δ 13C values for C3 and C4 species are -28 and -14, respectively. The leaf anatomy studies were consistent with the δ 13C results, where, in spite of the existence of parenchymatic cells forming a sheath surrounding the vascular tissue, the cells do not contain chloroplasts or starch. This characteristic is clearly different from that of the Kranz anatomy found in C4 species.

Aplicação exógena de artemisinina e indução floral em Artemisia annua L.

The objective of this work was to evaluate the effect of different artemisinin concentrations in the flowering induction of A. annua. Two genotypes of A. annua (CPQBA 239x1V and 3MxPOP) were atomized with four different artemisinin concentrations (0, 500, 5000, and 10000 mg L-1). The application of artemisinin didn't induce the flowering of both genotypes tested, in none of the used concentrations.

Efeito genotóxico da artemisinina e do artesunato em células de mamíferos

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Avaliação fitoquímica e microbiológica da espécie Artemisia annua L., submetida a tratamentos de armazenamento e condições de ambiente

Pós-graduação em Agronomia (Energia na Agricultura) - FCA