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23 April 2013

Malaria: the way forward…affordable medicines, vaccine or community health measures?


April 25th is World Malaria Day and we’ve had some mixed news this month concerning the GlaxoSmithKline RTS,S vaccine, reported in New England Journal of Medicine, which followed children for 4 years after being vaccinated. On the positive side, 65% of children were protected in the 1st year, but protection then declined to zero over the next 3 years: which means booster shots will be essential.  In addition, the vaccine's efficacy also declined faster in children who were more exposed to malaria than in those who had below-average exposure. Not the grail we hope for, but we inch our way there.

Effectiveness is at the heart of the problem of malaria control. In October 2012,  Oxfam’s report “Salt, Sugar And Malaria Pills  highlighted their concerns on the effectiveness of the “Affordable medicines facility for malaria” (AFMm) hosted and managed by the Global Fund, with financial support from UNITAID, the UK Department for International Development (DFID), and others. 

AFMm is designed to tackle malaria by making ACTs (artemisinin combination therapy, currently the most effective anti-malarial treatment), cheaper, more available, increase their use (especially by more vulnerable populations) & to displace ineffective drugs.   A laudable aim but Oxfam (and health professionals from my listserv HIFA2015, who live & work in malaria-endemic countries) worry that this  approach will bring with it problems of increased drug resistance & waste money which could be better spent on already effective measures i.e. the combination of insecticide-treated bednets, malaria drugs, insecticidal spraying,  & community health workers which has achieved reduction in cases in  Madagascar and another 4 African countries.

Drug resistance is a major problem for malaria control. ACTs were themselves introduced because of drug resistance to single drugs, and ACT resistance  already exists on the Laos-Cambodia border, where it is blamed  by international researchers on the “over-the-counter availability” and incomplete course treatment! A pre-conference video,  “Saving lives in the Asia-Pacific”, at the Malaria 2012 summit (Roll Back Malaria Partnership) told the story of a small community in northern Thailand facing drug resistance.

The AFMm strategy  is to subsidise the cost of ACTs and promote their sale through the private sector, recognising that most malaria medicines in African countries are sold over the counter at corner shops and market stalls.  After a successful pilot in 7 countries inc. Kenya, Nigeria and Ghana, in which they achieved their goals of improved access and reduced drug prices, as of November  14/15th 2012, this strategy is now  a core part of Global Fund to Fight AIDS, Tuberculosis and Malaria.

Oxfam’s 2012 report described the AFMm  as 'a dangerous distraction from effective public health measures', and  one which “has shown no concrete evidence that it has been effective at saving the lives of the most vulnerable, or in delaying drug resistance”.  Oxfam is still of that opinion Oxfam  reaction to the Global Fund's announcement on AFMm, considering that investment in community health workers is more effective than encouraging over-the-counter drug sales by untrained shopkeepers.

HIFA2015 members working in malaria-endemic countries considered in detail the issues raised by the Oxfam report and specifically looked at antimalarial drug prescribing, identifying 3 issues: overdiagnosis, misdiagnosis and mismanagement. These are their comments: 

  • Misdiagnosis by the untrained: access to antimalarials at African corner shops and market stalls, w/o prescription and sold & bought by the untrained, who cannot diagnose.
  •  Overdiagnosis by the trained: “30% of cases where ACTS are used to treat fever, assuming its malaria, the child actually has ARI, UTI or measles”. 
  •  Mismanagement:  “Most African children with malaria do not die from the infection but from its mismanagement  (ignorance in the carer or inappropriate drug dosage & timing of doses)”. “AS soon as the child feels better, administration of malria medisnc is stopped and the remaining dose preserved either for the next episode in the same child or the next episode in another child that fall sill with fever”.
  •  If AFMm goes ahead, we will need improved pharmacovigilance to identify adverse drug reactions
  • Health education of the public is needed
International research backs them up:
BMJ 2009, vol 339, Hopkins et al: “Based on typical malaria prevalence, for every billion dollars in subsidy on anti-malarials, around $500m-960m will be spent on people who do not have malaria.” “Misdiagnosis and over diagnosis of malaria drain resources at the household level, affecting poorest families most”.

The huge amount of malaria research in Global Health (over 51000 records indexed with Plasmodium, the disease-causing organism) and Global Health archive (another 32,000 records, dating back to 1911) is a reminder of how long people of good will and intelligence have struggled to deal with this disease AND of the huge strides made in recent years. I just wish they could agree!

On World Malaria Day, I hope to attend the All-Party Parliamentary Group on Malaria & Neglected Tropical Diseases in London and come away inspired.

 Further reading from Global Health and its Archive

 Hot off the press

High-level semi-synthetic production of the potent antimalarial artemisinin
Nature 2013.
Whilst this is good news for malaria sufferers, its likley bad news for poor farmers who are relying on growing sweet wormwood plant, the original source of this wonderdrug AND it could increase drug resistance, if increased production encourages use as a single drug rather than as an ACT.
For an examination of this read:





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