Anopheles mosquitoes exposed to long-acting antimalarials via drug-spiked bloodmeal absorb drug but do not suffer fitness costs

The World Health Organizations recommendations regarding the use of antimalarials for the prevention of malaria in endemic areas have greatly expanded, allowing more flexibility in the demographic groups and regions where chemoprevention and mass treatment are acceptable. An overlooked aspect of expanding human population-level drug exposure is the downstream impact of ingested drug on the mosquito vector. Data suggest both infected and uninfected Anopheles mosquitoes re-feed often with [≥]4 blood meals during their lifespan. This provides repeated opportunities for mosquitoes to ingest drug via bloodmeals taken from people with antimalarials in the bloodstream and raises questions as to whether exposure may impact the mosquito itself, and/or parasites developing within the infected mosquito. We investigated the impact of exposure to physiologic levels of commonly used long-acting human antimalarials in the Anopheles mosquito via drug-spiked blood feeds. We did not observe any significant differences in mosquito feeding, behavior, fertility, or viability after ingestion of amodiaquine, desethylamodiaquine, piperaquine, and sulfadoxine-pyrimethamine in either lab-reared An. gambiae or field-derived An. coluzzii mosquitoes. Interrogating drug distribution within mosquitoes utilizing LC-MS/MS, desethylamodiaquine, the longer-acting active metabolite of amodiaquine, was fed at 2 concentrations (1/2X and 2X Cmax) with drug subsequently detected in a dose-dependent manner in pooled whole mosquitoes, midguts and hemolymph. This was significant for whole mosquitoes harvested at 24hrs and 120hrs, and midguts harvested at 24hrs. Between 24 to 120 hrs, drug decreased in midguts but increased in hemolymph. Our results show biochemical evidence of antimalarial absorption into Anopheles hemolymph following bloodmeal ingestion. These studies lay the foundation for future work to assess the impact of vector-stage antimalarial drug exposure on parasite progression throughout development in the mosquito, which could in turn have important implications for transmission dynamics and drug resistance spread. Author summaryDrug resistance to first-line antimalarials has emerged in multiple African countries. A better understanding of antimalarial drug resistance emergence and spread is critical in preventing further morbidity and mortality. Millions regularly receive antimalarials for prophylaxis and mass treatment that are purposefully long-acting. Anopheles mosquitoes re-feed frequently, and these malaria vectors (both infected and uninfected) routinely feed on people whose blood contains these long-acting antimalarials. Parasites take approximately 10 days to develop within the mosquito. There is published precedent that several antimalarials can act upon vector-stage parasites, yet any potential impact of antimalarials on mosquitoes and/or parasites developing within has been largely overlooked. We questioned whether antimalarials ingested in mosquito bloodmeals could influence parasite development and drug resistance selection. As initial investigations, we exposed uninfected Anopheles mosquitoes to commonly used long-acting antimalarials via drug-spiked bloodmeals, mimicking predicted physiologic drug exposure. Investigated drugs did not impact mosquito viability. However, mass spectrometry confirmed drug absorption in whole mosquitoes, as well as within midguts and circulatory fluid, several days after feeding, demonstrating that mosquitoes can ingest key drugs without suffering fitness costs, and these drugs can persist in mosquitoes. This highlights the potential for antimalarials to impact parasite development and drug resistance selection within the mosquito.