Emergence and clonal expansion of in vitro artemisinin-resistantPlasmodium falciparum kelch13R561H mutant parasites in Rwanda

Artemisinin resistance (delayedP. falciparumclearance following artemisinin-based combination therapy), is widespread across Southeast Asia but to date has not been reported in Africa(1-4). Here we genotyped theP. falciparum K13(Pfkelch13) propeller domain, mutations in which can mediate artemisinin resistance(5,6), in pretreatment samples collected from recent dihydroarteminisin-piperaquine and artemether-lumefantrine efficacy trials in Rwanda(7). While cure rates were >95% in both treatment arms, thePfkelch13R561H mutation was identified in 19 of 257 (7.4%) patients at Masaka. Phylogenetic analysis revealed the expansion of an indigenous R561H lineage. Gene editing confirmed that this mutation can drive artemisinin resistance in vitro. This study provides evidence for the de novo emergence ofPfkelch13-mediated artemisinin resistance in Rwanda, potentially compromising the continued success of antimalarial chemotherapy in Africa. Identification in Rwanda of mutations inPlasmodium falciparumcapable of conferring in vitro resistance to artemisinin, an essential medicine for the treatment of malaria, underscore the crucial need for surveillance in Africa to safeguard efficacy of life-saving therapies.