Artemisinin Resistance in Southeast Asia

To the Editor—This letter is in response to the suggestion made by Phyo et al [1] that one of my publications [2] contributed to the spread of an epidemic of artemisinin resistance in Southeast Asia. I am flattered that authors consider my work so influential. However, I believe that several factors played a much larger role in the failure of the containment efforts. First, to paraphrase Mark Twain, reports of the death of artemisinin have been greatly exaggerated. Phyo and colleagues treated subjects with a combination of artesunate and mefloquine in the context of preexisting high-level mefloquine resistance. While K13 mutations, associated with artemisinin resistance, significantly increased the odds of failure, the effect size (absolute difference in cure rates) was small; in fact, they found no significant difference in polymerase chain reaction–adjusted cure rates between 2004 and 2013 (Table 1 [1]). I do agree with the authors, however, that the development of resistance to artemisinin partner drugs is worrisome. Second, all genetic evidence currently suggests that the K13 mutations pop up multiple times, independently, in different locations and are not spread spatially. Thus, walling off artemisinin resistance geographically is not possible. What the malaria control community needs is a “whack-a-mole” approach, utilizing robust surveillance and targeted responses. Finally, given the very limited resources available to malaria control, many respectable public health practitioners feel that more funds should be channeled to Africa where 90% of the world's malaria deaths occur. Every dollar spent in “containing” the future spread of artemisinin resistance is one less dollar spent on treating children now. I applaud the dedication and enthusiasm of the MORU team. But important public health decisions require being open-minded to different points of view. Potential conflict of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.