UNIVERSITY OF PENNSYLVANIA - AFRICAN STUDIES CENTER
Africa: Malaria Treatment Date distributed (ymd): 020222 Document reposted by Africa Action
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Region: Continent-Wide Issue Areas: +economy/development+ +health+
This posting contains a press release and excerpts from a report released by Medecins Sans Frontieres (MSF) last week in Nairobi, calling for the use of new, more effective drugs against malaria. These medically recommended drugs are not being used, MSF said, simply because of cost. Rich countries could easily finance the modest additional cost and save many of the 1.5 million to 2 million a year who die from malaria, the vast majority of them African children.
$19 million a year, for example, would pay for treatment in the five east African countries examined in detail in the MSF study. The increase in cost today would be repaid many times over by future benefits, note the report's authors.
In the press conference releasing the report, MSF spokesperson Daniel Berman noted that among donor agencies, the U.S. Agency for International Development was particularly active in opposing funding for the more effective drugs (see Washington Post, February 14, 2002).
The World Health Organization, in a report on macroeconomics and health in December and a new report on Scaling Up the Response to Infectious Diseases in January, has stressed that increased investment in combatting malaria, TB, HIV/AIDS and other infectious diseases would provide enormous economic benefits for development as well as saving lives. See: http://www.africaaction.org/docs01/who0112.htm and http://www.who.int/inf/en/pr-2002-06.html
For an earlier background overview on malaria see http://www.africaaction.org/docs00/mal0005.htm
Additional links on malaria, HIV/AIDS and other global health issues can be found at: http://www.africaaction.org/action/health.htm
M,decins Sans Frontieres (MSF) Press Release
Number One Killer of Children in Africa Too Expensive to Treat Effectively?
Report released by MSF shows this myth is unfounded
The full report "Changing national malaria treatment protocols in Africa: What is the cost and who will pay?" can be found on http://www.accessmed-msf.org.
For further information, please contact Daniel Berman on +254 733 631531, Malini Morzaria on +254 72 513 981 or Lucy Kange'the on +254 2 444474 or +254 2 440536.
13 February 2002, Nairobi -- As East African countries are about to change national malaria treatment protocols, Medecins Sans Frontieres (MSF) today releases a report in the hope of averting a fatal choice.
In recent years, increasing parasite resistance has rendered antimalarial drugs such as chloroquine and Fansidar virtually useless in many parts of East Africa. Malaria experts agree that in order to offer patients effective treatment and prevent further spread of resistance, protocols should include drug combinations with the highly potent Chinese drugs known as artemisinin derivatives.
However, because of a lack of resources and donor preference for cheap solutions, many health ministries are considering changing protocols to transition strategies, using combinations of drugs that will be equivalent to giving some patients placebos. This decision is a matter of life and death in a disease that kills between 1.3 and 1.8 million African children a year.
"Knowing more effective drugs are available and not being able to give them to my patients has been so difficult," said Dr. Diane Cheynier, MSF Burundi. "Treatment exists that can avoid people dying unnecessarily. With the help of donors, African governments can avoid the fatal error of going to stop-gap, band-aid solutions."
In MSF's report, increased costs of more effective drugs are pinpointed as one of the chief barriers to widespread implementation in the public sector. Current drug combinations cost just US$0.25 per adult dose while more effective combinations with artemisinin derivatives cost approximately US$1.30. However, the report shows that for Burundi, Kenya, Rwanda, Tanzania and Uganda combined, the additional costs to implement the more effective combinations would only amount to US$19 million a year.
When African governments make the political decision to implement effective long term strategies, they will need the support of donors.
"We believe that the report released today destroys one of the key myths blocking the introduction of treatment that has been highly recommended by leading malaria experts," said Dr. Jean-Marie Kindermans of MSF, author of the report. "The cost of switching to effective combinations rather than combinations which are often no better than placebos is affordable if international donors are willing to help."
Artemisinin derivatives, which are extracted from a
Chinese plant and have been used in Asia for more
than ten years, have attributes that make them especially
effective against malaria and are therefore viewed
as essential elements of effective combinations. They
are fast-acting, highly potent and complementary to
other classes of treatment. When used in combination
with a second drug, artemisinin derivatives appear
to slow the development of resistance to the second
drug. For this reason, experts predict that artemisinin-containing
combinations would continue to be effective in the
long term. To date, no resistance to artemisinin drugs
has been reported.
Press Dossier Excerpts only (for full text - 15 pages - see http://www.accessmed-msf.org)
Changing national malaria treatment protocols in Africa: What is the cost and who will pay ?
(summary of a paper by Jean- Marie Kindermans)
13 February 2002 Nairobi, Kenya
Malaria: a few facts
Every year, there are an estimated 300 to 500 million cases of malaria in more than 90 countries worldwide. Ninety percent of cases occur in Africa.
Of the four species of malaria parasites, Plasmodium falciparum is responsible for most deaths - 1.5 to 2 million a year, ninety percent of which are African children.
Malaria remains the first cause of death for children under five in Africa - children are more vulnerable to the disease than adults because their immunity is less developed.
Malaria not only cuts lives short but has a huge socio- economic impact: patients are often bedridden and incapable of carrying out normal daily activities, therefore suffer considerable loss of income and place a heavy burden on their families, the health system and society as a whole.
Malaria treatment protocols include both first-line and second-line treatment. Patients with uncomplicated malaria are treated with first-line drugs. Patients with severe malaria and those who don't respond to first-line treatment are treated with second-line drugs.
Resistance to anti-malarial drugs
In Africa, national treatment protocols have traditionally mandated use of one anti-malarial drug, either chloroquine or Fansidarr as first-line treatment. But in recent years, resistance to these drugs has increased dramatically.
Experts now strongly recommend changing protocols to include a combination of drugs. By hitting different biochemical targets of the parasite, drug combinations are more effective and allow for shorter treatment courses. As importantly, they protect each individual drug from resistance.
It is widely agreed that the best current treatment solution is to use artemisinin-containing combinations. Artemisinin derivatives - which are extracted from a Chinese plant - have attributes that make them especially effective: they are fast-acting, highly potent and complementary to other classes of treatment. To date, no resistance to artemisinin-containing combinations has been reported.
National treatment protocols
Despite all the evidence in favour of artemisinin- containing combinations, many governments are changing their malaria treatment protocols from chloroquine to another drug used on its own (= in "monotherapy"), or to a combination of drugs that doesn't include artemisinin derivatives.
For example, several countries in the East African Network for Monitoring Antimalarial Treatment (EANMAT) have recently switched from chloroquine to Fansidarr monotherapy for first-line treatment of malaria. Considering the high levels of resistance to Fansidarr in East Africa (e. g. up to 60% or more in parts of Burundi and Uganda), this short-sighted policy is likely to lead to continued increases in morbidity and mortality as well as a rapid rise in resistance to Fansidarr.
Effectiveness versus cost
Ministries of health are aware of the drawbacks of Fansidarr monotherapy and are planning to introduce combinations. But most are not planning to use the more effective artemisinin derivatives.
It's a question of cost: using a combination of amodiaquine and Fansidarr may be less effective and more likely to increase resistance rates, but treating one adult costs just US$ 0.25. Using the more effective combination of amodiaquine and artesunate (an artemisinin derivative) costs US$ 1.30. Coartemr (artemether/ lumefantrine) has the further advantage of being easy to use, because the combination has been developed as a one-pill co- formulation - but it costs US$ 2.40 per adult dose.
Rwanda has 1.2 million cases of malaria every year and is about to change its national treatment protocol. It has been estimated that it would cost the country an extra US$ 945,000 per year to introduce artemisinin- containing combinations rather than a less effective combination. For Burundi, with 2 million cases of malaria a year, the switch would cost an extra US$ 1.6 million per year. For Burundi, Kenya, Rwanda, Tanzania and Uganda combined, the annual cost would be US$ 19 million.
Historical experience shows that the prices of artemisinin-containing combinations are likely to decrease over time as more producers are validated and competition is encouraged. We estimate that the price of the amodiaquine + artesunate combination will decrease from US$ 1.30 to US$ 0.60 by 2004. In this case, the supplementary cost of using the most effective treatment would come down to US$ 6.3 million per year for the five countries combined.
Longer term savings can be achieved by using artemisinin combinations
MSF believes that the only way to prevent the widespread use of sub-optimal, ineffective treatment and further malaria epidemics is to find resources to fund the use of more effective drugs.
The increase in cost today will be repaid many times over in years to come. Using effective treatment saves lives, reduces the number and length of medical consultations and hospital stays, and avoids the expense of ineffective treatment. People return more quickly to their families and workplace, thus reducing the enormous socio-economic burden of the disease.
International aid will be needed
Malaria is one of three priority diseases that the international community has committed to fight. UN secretary general Kofi Annan has estimated US$ 8 billion a year will be needed for the Global Fund, but so far only $1.9 billion has been pledged and even this amount is to be spread over a three year period.
Providing the cash to change national malaria treatment protocols in East Africa in a sustainable manner is a worthwhile investment and a pragmatic step in combating one of the leading killers in Africa today. Action must be taken now to avoid the needless deaths that will be caused by using treatment that no longer works.
Conclusions / recommendations:
1. When considering changing national treatment protocols, it is essential that financial considerations do not lead to sub- optimal medical choices. Effective drugs that can save lives are available and must be included in national protocols. Other "transition" strategies are shortsighted and merely postpone the necessary switch to more effective treatment. They will also lead to increased incidence of disease and drug resistance. The so- called "transition" strategy proposed by several countries may in fact remain in place for longer than expected, as protocol change is a difficult, expensive process which cannot be repeated every few years. It will also be more expensive in the long-term when it becomes essential to switch to more expensive drugs such as quinine, mefloquine or co-artemether.
2. Developing countries should not be forced to cope with the financial burden of improving malaria treatment on their own. Malaria is a growing worldwide crisis and international aid should be forthcoming to help implement practical solutions. International leaders must follow up on their political rhetoric and make available promised resources. There is great urgency in the case of malaria, and moderate investment can concretely improve treatment and save lives - it is a chance to transform words into actions.
Furthermore, considering that international aid covers a significant proportion of the health budget of some developing countries, donors have an ethical responsibility to ensure that interventions are medically appropriate. WHO should work proactively to support the ministries of health in developing countries to adopt effective malaria protocols.
3. Antimalarials produced in Asia should be made available in Africa as soon as possible. UN organisations have a role to play: WHO should expand the existing AIDS drug pre-qualification system to malaria and UNICEF can directly support procurement and distribution.
4. In the long term, a considerable increase in research and development for malaria treatment is also necessary. Medicines for Malaria Venture (MMV) and other research initiatives should be actively supported.
Case studies - Kenya
Malaria cases in a Nairobi slum
Pamela is 35. She lives in Huruma, at the edge of the Mathare slum in Nairobi. For several days now, she has been feeling very ill. She has fever, headaches and she has been vomiting. Washing clothes is her only source of income, but she's too ill to work. She thinks she has malaria -- she's had it before, especially after going to her village near Kakamega in the Western Province. That's what happened last time she went there, for Christmas day.
So Pamela bought three tablets of Fansidar (SP) and took them herself. But despite this, she is still ill. And scared too -- her sister died of malaria last year. She's heard that other more effective drugs exist, but that they are expensive, so she won't be able to pay for them.
Pamela therefore decides to go to MSF's clinic in Upendo, in the Mathare slum, where she's been treated two or three times for other problems without having to pay too much. At the clinic, she has to wait for a while in the queue before Florence, the nurse, can see her. Pamela explains her symptoms and that she's already taken three malaria tablets. Florence immediately sends her to the clinic's small laboratory to carry out a blood test and see if she has parasites in her blood -- it's positive. The nurse sends Pamela to consult Moussa, the clinical officer, who explains that the tablets she took didn't cure her because the parasites are resistant to that drug, but that she's going to take another, much more effective treatment. Moussa prescribes a three-day course of artesunate and amodiaquine. He gives her the pills and watches her take the first dose.
Pamela goes back home and already feels better a few hours later. A few days later, she is totally cured and has started working again.
Christopher, 10, lives in Mathare 4A with his widowed mother and his four brothers and sisters. The family has gone back to their village but returned to the slum two weeks ago. Christopher fell ill -- he had fever and a cough, so his mother took him to the Upendo clinic where she usually goes.
A nurse examines Christopher and takes a drop of blood taken from him to carry out a rapid diagnostic test. Five minutes later, the nurse confirms that the test is positive for malaria. She prescribes Fansidar, and explains to his mother that she must bring him back if he doesn't get better.
Three days later, Christopher is still ill and his mother brings him back to the clinic. This time, the nurse asks the lab technician to carry out a microscopic blood test, which shows the parasite is still present in his blood. Moussa, the clinical officer, prescribes Christopher a combination therapy of artesunate and amodiaquine.
Christopher doesn't have to go back to Upendo a third time. Instead, he goes back to his neighbourhood's informal school.
Editor: Ali B. Ali-Dinar
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