Why war against malaria is failing, by experts

The life-threatening disease caused by parasites transmitted to people from the infected female Anopheles mosquito bites is not only preventable but curable with anti-malarial drugs. But many Nigerians still fall sick despite the introduction of a combined therapy – Artesunate Combination Therapy (ACT). OYEYEMI GBENGA-MUSTAPHA examines the factors responsible.

THE war against malaria has been on for a very long time, but it is far from being won. It remains a life-threatening disease in the developing countries.

Medical experts have attributed fund paucity, drugs counterfeiting and dearth of research as some of the problems that make the various interventions by governments and donor-agencies ineffective.

According to a 2015 World Health Organisation (WHO) report, there were more than 200 million cases of malaria and 437 000 deaths. More than 90 per cent of malaria deaths occur in Africa.

Going by this year’s report, no appreciable progress has been made in malaria control. The report estimated five million more malaria cases in 2016 than in 2015. Malaria deaths stood at around 445 000, a similar number to the previous year.

Insufficient funding at the domestic and international levels has been identified as a major problem. There have been gaps in the provision of insecticide-treated nets, medicines and other life-saving tools.

But to WHOs Director-General, Dr. Tedros Adhanom Ghebreyesus, major gains have been made in the anti-malaria battle.

He said: “In recent years, we have made major gains in the fight against malaria. We are now at a turning point. Without urgent action, we risk going backwards, and missing the global malaria targets for 2020 and beyond.”

The WHO Global Technical Strategy for Malaria plans to achieve a 40 per cent reduction in malaria case incidence and mortality rates by 2020.

A wake-up call

Reacting to the latest WHO report, the Director, Global Malaria Programme, Dr. Pedro Alonso, said: “We are at a crossroads in the response to malaria. We hope this report serves as a wake-up call for the global health community. Meeting the global malaria targets will only be possible through greater investment and expanded coverage of core tools that prevent, diagnose and treat malaria. Robust financing for the research and development of new tools is equally critical.”

Many local medics have adopted the new malaria treatment standard – screen for malaria before treating a patient by using the rapid diagnostic malaria kit. Yet, when malaria is diagnosed and treatment initiated, the patient does not get any better. What then could be responsible?

Role of fake drugs

According to the WHO, anti-malarial and antibiotics are amongst the most commonly reported substandard and counterfeited products. Malariariologist and Head of Department, Public Health & Epidemiology, Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, Dr. Sam Awolola, said both generic and innovator medicines can be faked.

The products, according to him, range from very expensive products for cancer to very inexpensive products for pain treatment. They can be found in illegal street markets, via unregulated websites, pharmaceutical stores, clinics and hospitals.

According to him, one out of every 10 medical products in low and middle-income countries, including Nigeria is either substandard or counterfeited.

The substandard and faked medical products contribute to anti-microbial resistance and drug-resistant infections.

Research has shown that counterfeited products could contain no active ingredient, wrong active ingredient, or the wrong amount of the correct active ingredient.

The products contain corn starch, potato starch or chalk. Some substandard and falsified medical products have been toxic in nature with either fatal levels of the wrong active ingredient or other toxic chemicals.

All substandard and adultrated products are often produced in very poor and unhygienic conditions and by unqualified personnel. They contain unknown impurities and are sometimes, contaminated with bacteria.

The counterfeited products are by their nature difficult to detect from the original. But, they fail in treating the disease and often lead to serious health complications, including death.

A top official at the Nigerian Agency for Food and Drug Administration and Control (NAFDAC), who spoke under the condition of anonymity, urged consumers to assist the agency in tackling the challenge of fake products.

The official said: “Because we have high technology cutting devices to checkmate these fakers, but should some escape our vigilance, consumes should call our attention to same.”

He advised consumers to be cautious of spam email advertising medicines; lack of authenticity; no verification logo or certificate; spelling mistakes and poor grammar on the packaging.

Besides, he said that websites that do not display a physical address or landline and websites offering prescription only medicines without a prescription, and suspiciously low-priced products, must not be patronised.

According to the WHO, the checklist must be applied for online purchase.

The organisation listed the questions to which due attention must be paid as: Is it exactly the medicine ordered? Is it the correct dosage? Is the packaging in good condition, clean, with a patient information leaflet and in the language in which it was advertised? Does the medicine look, feel and smell as it should? Are security seals intact with no signs of tampering? Does any customs declaration or postal label declare the contents as medicines? Does the batch number and expiry date on the primary internal packaging match the batch number and expiry date on the secondary (external) packaging?

By last month, WHO had issued 20 global medical product alerts and numerous regional warnings, and provided technical support in over 100 cases.

In Borno State, for example, WHO supported the launch of a mass antimalarial drug administration campaign that reached about 1.2 million children aged under-five years in targeted areas.

The early results have shown a reduction in malaria cases and deaths in the Northeast state.

Malariologists and other experts in the field of control believe that all hope is not lost on the elimination of the killer-disease.

Prevention

According to the experts, vector control is the best way to prevent and reduce malaria transmission. They said that with a higher coverage of vector control interventions within a specific area, a measure of protection will be achieved across the community.

WHO recommends protection for all people at risk of malaria with effective malaria vector control and the two forms of control are: insecticide-treated mosquito nets and indoor residual spraying.

Insecticide-treated

mosquito nets

Long-lasting insecticidal nets (LLINs) are the preferred form of insecticide-treated mosquito nets (ITNs) for public health programmes. In most settings, WHO recommends LLIN coverage for all people at risk of malaria. The most cost-effective way to achieve this is by providing LLINs free of charge, which Nigeria has imbibed, to ensure equal access for all. In parallel, effective behavioural change communication strategies are required to ensure that all people at risk of malaria sleep under a LLIN every night, and that the net is properly maintained.

Indoor spraying with

residual insecticides

Indoor Residual Spraying (IRS) with insecticides is a powerful way to rapidly reduce malaria transmission. Its potential is realised when at least 80 per cent of houses in targeted areas are sprayed. Indoor spraying is effective for three to six months, depending on the insecticide formulation used and the type of surface on which it is sprayed.

In some settings, multiple spray rounds are needed to protect the population for the entire malaria season. Lagos is one of the states that have applied the spraying method.

Anti-malarial drugs

Antimalarial drugs can also be used to prevent malaria. For pregnant women living in moderate-to-high transmission areas, WHO recommends intermittent preventive treatment with sulfadoxine-pyrimethamine, at each scheduled antenatal visit after the first trimester.

Also for infants, three doses of intermittent preventive treatment with sulfadoxine-pyrimethamine are recommended, delivered alongside routine vaccinations.

In 2012, WHO recommended Seasonal Malaria Chemoprevention as an additional malaria prevention strategy for areas of the Sahel sub-region of Africa. The strategy involves the administration of monthly courses of amodiaquine plus sulfadoxine-pyrimethamine to all children under-five years of age during the high transmission season.

Dr. Awolola said the best anti-malarial drug the world had ever known: chloroquine was safe, cheap and effective, until the malaria parasites developed resistance to it.

He said that Sulphadoxine pyrimethamine is a drug combination with a lot of promise which the parasites also became resistant to.

The malariologist said: “The drawback of drug resistant malaria is a global concern. The main fear is that drug resistance will trigger intense transmission patterns.

“Over the last century, the use of monotherapies, like quinine, chloroquine, mefloquine, lumefantrine, pyrimethamine and halofantrine, have led to rapid resistance by Plasmodium falciparum.”

Describing the banning of monotherapies expected, he said what should be of interest is “whether our healthcare practitioners truly believe in the failure of monotherapies is another subject.

“Chloroquine, though under proscription is still the drug of choice for many physicians today, evidence from our work showed that indeed molecular markers of resistance to this drug is very much in circulation.”

On the current recommended anti-malarial drugs: Artemisinin-based Combination Therapies (ACTs), Dr Awolola said that ACTs kill the parasites in the blood of the infected person within three day.

“Arthemether-lumefantrine is presently the mostly favoured ACT use as first or second line treatment in Nigeria and other African countries.However, in 2003, only one years after WHO recommended that ACTs be used everywhere, delayed parasite clearance in P.falciparum, suggesting artemisinin resistance was reported close to the Thailans-Cambodia border in South-East Asia,” he said of the discovery of ACTs as a great hope for malaria treatment.

In 10 years, Awolola said the spread of artemisinin resistance expanded substantially across the Greater Mekong sub-region from the coast of Vietnam in the East to the border of India in the West.

He said these resistant parasites have already been shown capable of infecting the main African vector Anopheles gambiae, “signs that artemisinin resistance is developing in Africa is emerging from studies conducted by researchers from London School of Hygiene and Tropical Medicine who discovered a new genetic mutation – ‘ap2mu’ that makes P.falciparum less sensitive to artemisinin, which may mean the beginning of ACTs resistant P.falciparum in Africa.”

Awolola decried the relatively little contributions of African governments malaria research funding, as he explained: “today, Africa still harbours the burden of the disease. Yet, funding for malaria research is donor-dependent in an era where we all dream of elimination. The statistics of funding malaria research by African governments is precarious and the Nigerian situation is pathetic.

“An assessment of funding malaria at NIMR from 2007 to 2016 showed shocking statistics with above 80 per cent provided through external support, while Nigerian Government through the Federal Ministry of Health offered less than seven percent. If we ignore the responsibilities of today, we cannot elude the challenges of tomorrow.”

Insecticide resistance

Awolola told those who still believe in the use of ITNs that much of the success recorded malaria control came from vector control. Vector control is highly dependent on the use of pyrethroids, which are the only class of insecticides currently recommended for ITNs or LLINs.

But mosquito resistance to pyrethroids has been recorded in many countries. In some areas, resistance to all four classes of insecticides used for public health has been detected. The resistance are rarely associated with decreased efficacy of LLINs, which continue to provide a substantial level of protection in most communities.

Rotational use of different classes of insecticides for IRS has been recommended as one approach to manage insecticide resistance.

However, malaria-endemic areas of sub-Saharan Africa and India are posing significant concern due to high levels of malaria transmission and widespread reports of insecticide resistance.

The use of two different insecticides in a mosquito net offers an opportunity to mitigate the risk of the development and spread of insecticide resistance nets.

From: Thenationonline news

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