Malaria: getting our act together

MALARIA: Getting Our ACT Together
Paul J. Oyier
On Tuesday, 25th April, 2006, Kenya joined the continent and indeed the world, in marking the 6th Africa Malaria Day, with the theme: Get Your ACT Together.
Kenya’s Health Minister, Hon. Charity Ngilu, led stakeholders in the fight against malaria by marking the day at the Kitui Stadium in Kitui District. On May 11th 2006, the world marked yet another malaria-related day, the International Fast Day Against Malaria, with leaders, scientists and representatives from international bodies fighting the disease, fasting for 24 hours in order to move the world into Why the big fuss? Put simply, by the time we mark Africa Malaria Day next year, or think about fasting for the disease next year, more than one million children will have died of malaria, 90% of them in Africa, with Kenya losing 34,000 children and 20,000 pregnant mothers. In addition to these staggering malaria mortality statistics, its effects on morbidity are just as stark, contributing significantly to anaemia in children and pregnant women, adverse birth outcomes such as spontaneous abortion, stillbirth, premature delivery and low birth weight. Furthermore, in countries with the highest burden of the disease, like Kenya, it has been estimated that malaria is responsible for an average annual reduction of approximately 1.3% in economic growth, and accounts for 30-50% of all hospital outpatient visits and 20% of all admissions. Despite this, the commemorations at Kitui Stadium on that sunny Tuesday escaped the attention of most of us, perhaps because of familiarity or a simple lack of interest. Whatever the reason, this year’s commemoration signalled a change in strategy for the treatment of malaria in Kenya. Announcing the change, Hon Ngilu said, “I am happy to report now that we have just concluded the development of the treatment policy for Artemisinin Combination Therapy (ACT) as first line treatment for malaria to replace the single drug treatment with SP (Sulphadoxine- Pyrimethamine), which has been in use and has shown very high treatment failure The change from Sulphadoxine-Pyrimethamine (SP) or Sulphur based treatment like the popular Fansidar has been occasioned by the resistance of the malaria parasite to the drugs. Isabella Ochola, a doctoral student specializing in malaria research at the University of Liverpool’s School of Tropical Medicine, notes that “The available anti-malarial drugs have not changed much over the past few decades; however, the parasite has developed ways of protecting itself, resulting in the new global challenge of curbing the latest brand of drug resistant parasites.” The malaria parasite has developed resistance, not only to Sulphadoxine- Pyrimethamine (SP) but previously also to Chloroquin (CQ). These are commonly referred to as mono-therapies in contrast to the new combination therapy, ACT. According to Ochola, the resistance to these mono-therapies could have been prevented through proper usage of the drugs: “Sadly, the development of resistance to CQ and SP is due to drug misuse, mainly the improper intake of the drugs through incomplete doses because of poor drug administration at medical centres, where there is minimal emphasis on the importance of completing the full drug course, thus resulting in poor compliance. Additionally, poverty affects patients’ compliance, as they are unable to buy the full dose required to treat malaria which causes improper exposure of the parasite to the drugs resulting in a recurrence of the disease, due to the parasite’s rapid proliferation rate which makes it able to genetically evolve every 48 hours, producing a strain of the parasite that is The World Health Organisation (WHO) which is aware of these facts, recommended the withdrawal of Sulphur-based drugs or mono-therapies like Fansidar and Metakelfin in 2001, to be replaced by the new artemisinin-based combination therapy (ACT), branded as Coartem, and manufactured by Novartis Pharmaceuticals. It is under this recommendation that our Health Ministry formally announced the change in policy on April 25th 2006. Artemisinin was ‘discovered’ from the Sweet Wormwood (Artemisia annua) by Chinese scientists in 1972, when they isolated the active compound, sesquiterpene lactone, from the shrub. There are currently no artemisinin-resistant parasites, which means it can be used to treat multi-drug resistant strains of malaria. In an attempt to keep it effective longer, the WHO recently recommended its use in combination therapy, as opposed to mono-therapy. Indeed, Ochola also notes that, “Currently, artemisinin combination therapies (ACTs) provide the most effective means of treatment of multi-drug resistant malaria and at the same time they preserve artemisinin efficacy against malaria.” However, while most medical experts agree that the change in policy was long overdue, many have voiced reservations, especially about the high cost of Coartem. This is a fact that even Health Minister Charity Ngilu could not escape, when she admitted that, “…the challenge to the Government regarding this change is to continually secure the resources to support this procurement and distribute ACTs to all levels of care in Kenya.” Coartem sells at about 90 US cents (for children) and $2.40 (for adults) in the public sector and between $7 and $10 in the private sector, this compared to chloroquine for example, which sells at 20 US cents. This cost is well out of reach of ordinary Kenyans, which is why the Global Fund has committed itself to fund the cost of ACT drugs in the public sector to the tune of Ksh. 34 million over the next two years. However, questions are being asked about what will happen after two years.
Prof. Isaac Kibwage, the Chairman of the Pharmaceutical Society of Kenya (PSK) voiced these concerns, when he told a local weekly paper, “ACT is effective, no doubt. But donor-funded programmes are founded on the ever-shifting quick sands of politics. Our (PSK) position is that the government should only change policy based on its ability to pay and not on donor pressure. We are concerned that patients and the Government will not afford the drug when donors leave.” He went on to add, “PSK is also opposed to the adoption of a strong drug like Coartem [as] a first-line treatment drug, which will create serious problems once patients On the cost issue, Dr. Willis Ahwale, the Head of the Malaria Control Programme at the Ministry of Health, says that the Government can afford the cost of Coartem even after donors withdraw, and that Kenya will start manufacturing generics when the aid programme ends. However, the Sweet Wormwood or Artemisia plant has been grown in Kenya for years in Kiambu, Kajiado and Rongai, and Ochola argues, “The drug (artemisia) should be grown in the region as means of reducing the costs of the drug to the local population so that we are not dependent on the western pharmaceutical industries who commandeer the prices of drugs required by the poor and vulnerable in society. The manufacture of the drug on site and its local distribution should make it available at a cheaper price to the consumer.” This is an option the Government should consider from a commercial aspect instead of relying on imports since the raw materials for saving thousands of lives Indeed, artemisinin has been administered by herbalists in Kenya as a “tea” with amazing success-rate against the disease. However, a word of caution is in order given the fact that “Kenyan herbalists growing and administering artermisinin must also exercise due diligence as artemisinin is the only line of defence available worldwide for multi-drug resistant malaria,” according to Ochola, who goes on to add, “The unprotected administration of artemisinin as a monotherapy will encourage the development of artemisinin resistant parasites, thus sentencing the continent to death as the production of new drugs is quite slow and there will be no treatment available.” The “tea” administered by Kenyan herbalists, is mono- therapy, and the WHO fears that it could result in resistant malaria parasites, the reason why it is recommending combination therapies. But this view is opposed by a highly vocal pro-artemisinin lobby, which argues that the Chinese have been using the “tea” for over 2,000 years and that the malaria parasite is yet to develop The concerns of all these stakeholders are important, and must be addressed fully in order to deal with the common enemy. There is a need to make ACTs available to those in need, those most vulnerable to malaria, and to educate the public and even our herbalists on combination therapies for malaria (if it is true that the malaria parasite could develop resistance). In brief, we need to move fast because by the next issue of this journal over 50 Kenyan children will have died of malaria.

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