Saving Lives, Buying Time Economics of Malaria Drugs in an Age of Resistance (2004) / Chapter Skim
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Part 1: A Response to the Current Crisis1 Malaria Today
Part 1: A Response to the Current Crisis1 Malaria Today
Pages 17-60
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PART 1 A Response to the Current Crisis Treatment of multi-drug resistant falciparum malaria on the North-Western border of Thailand. Photo credit: Dr.
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There also is evidence that drug resistance is leading to epidemics in fringe areas where malaria was previously well controlled when chloroquine was effective. The IOM Committee on the Economics of Antimalarial Drugs was constituted to study the economics of making effective antimalarials accessible to those who could benefit from them.
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It was largely in connection with its leadership role in RBM that USAID approached the Institute of Medicine for independent advice and economic recommendations to counter the current global crisis in antimalarial drug resistance. The Bill and Melinda Gates Foundation later joined as a study cosponsor.
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Malaria Control Chapter 9. Antimalarial Drugs and Drug Resistance Part 3: Advancing Toward Better Malaria Control Chapter 10.
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The main reasons for endorsing artemisinin-containing combinations are: · the artemisinins represent a new family of compounds, with a novel mode of action, and faster antimalarial activity than any of the other drugs; · they have proven themselves robust over at least a decade of consistent use in Asia, both in terms of effectiveness and safety and in the lack of any documented drug resistance (at least in part because they have a re 1SP and Lapdap both are made up of two drugs but are not considered combinations in the sense of ACTs because the mechanisms of action of the two drugs are linked, and the individual drugs are not fully effective antimalarials.
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At least 85 percent of deaths from malaria occur in Africa, 8 percent in Southeast Asia, 5 percent in the Eastern Mediterranean region, 1 percent in the Western Pacific, and 0.1 percent in the Americas.
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It is worth remembering that the malaria map would have looked very different half a century ago, and that control measures are largely responsible for shrinking the highly-endemic zone. The low- and no-transmission areas of southern Africa (including Namibia, Swaziland, South Africa, Botswana, and Zimbabwe)
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1999. A Climate-Based Distribution Model of Malaria Transmission in Sub-Saharan Africa.
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Unlike other adults in endemic areas, pregnant women are themselves more susceptible to malaria's most severe effects -- including death -- and asymptomatic infection of the placenta significantly reduces the weights of their newborn children, reducing their chances of surviving infancy. Some proportion of those who survive severe malaria -- with or without effective treatment -- are left with permanent, serious effects, including epi 2Chapter 6 gives a detailed account of the disease and its effects, which are summarized briefly here.
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. In the absence of effective prevention, treatment of symptomatic cases is the most common form of malaria control.
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A physician reviews the entire record and assigns the final cause. From the full details of each case, treatment can be divided broadly into "modern care" -- which includes biomedical, Western, pharmaceutical, pro 3Not all verbal autopsies use the exact method described here.
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. TEHIP is continuing to refine the information from this study and will be analyzing the narrative portion of the verbal autopsy questionnaires to look at some specific aspects of the health care received, including: · reasons for delay in seeking modern care (e.g., tried to treat at home without antimalarials, no transport, poor recognition of severity, lack of confidence in modern care, no power to decide, insufficient finances)
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When malaria is suspected, people may go to one of a wide range of places (although in a given place, the choices may be few) , including modern health providers in public clinics or health centers of various sizes in private facilities run by religious groups or other nongovernmental organizations; or the commercial private sector, which includes traditional healers, pharmacies, shops, markets, and drug peddlers.
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In one site in rural Tanzania in the early 1990s, 90 percent of the children under 5 who died from acute febrile illness with seizures, died at home. Most (85 percent)
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· Health facilities frequently are out of stock of essential drugs including antimalarials, and the malaria peak in some countries coincides with the end of the financial year, exacerbating the problem at a key time. · Second- and third-line drugs may not be made available to lower level health facilities, despite the high frequency of treatment failure with the first-line remedy.
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Private clinics and other outlets have their problems too. While staff attitudes may be better and waiting times shorter, private facilities may not have as wide a range of equipment or trained staff as in the public sector (Silva et al., 1997; Mutizwa-Mangiza, 1997)
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Malaria accounts for 36.7 percent of all outpatient attendance, 62.1 percent of inpatient admissions, and 10.3 percent of pregnant women seen at health facilities. About two million of Cambodia's 12 million population are at risk of malaria.
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In each sector, drugs flow into the system from large importers and some local manufacturers, who supply outlets lower down in the chains. Drug flows in each country are depicted schematically in Figures 1-2, 1-3, and 1-4.
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However, private sector use is increasing and use of public health facilities is decreasing, in part due to only partially effective exemption mechanisms for the poor and frequent drug shortages in the public sector.
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Private Chemists (1,000) Patient/Caretaker Private Network Public Network Pharmaceutical raw materials INN generic drugs Patented drugs and brand name generic drugs Population purchase FIGURE 1-2 Organization of distribution networks for antimalarial drugs in Senegal, excluding the parallel market.
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Public sector drug procurement and distribution are centralized and, since 2002, procurement has been through an open tender system. Drug needs for malaria are determined by the National Malaria Center (CNM)
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Trained community based providers Health Facilities Patient/Caretaker Private/Social Marketing Public Patented drugs and generics Population purchase FIGURE 1-4 Flow of drugs in Cambodia, including public and private sectors. which informs the Central Medical Stores how much of each drug to send to each province.
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Unlike the situation in Senegal, the private sector cannot purchase drugs from the public sector to sell in private outlets. Private distributors deliver drugs only within Lusaka, the capital, and to towns on the railway line to the Copper Belt and the Southern province.
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The illegal market is allegedly supplied from many sources, including organized smuggling networks, the private sector, leakage from the public sector, occasional diversions from the Dakar port or airport, illegal or declared imports of donations collected in France and in other countries
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Although no longer provided through the public sector, there are still considerable sales of chloroquine in the private sector. In addition, more than a hundred different brands, presentations, and forms of antimalarials are available in the private market as branded products, generics, and branded generics, representing about 14 different compounds.
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was introduced as the first-line drug in 1999, with a recommendation that all first-line drugs be based on a diagnosis by either microscopy or a rapid dipstick test. The combination is available as "A+M" in the public sector and is socially marketed in the private sector as "Malarine." Dipsticks also are socially marketed in the private sector.
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1.63 2.13 SOURCE: Shretta and Guimier, 2003. Zambia Drugs in the public sector are financed by a combination of government funds and user fees.
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A factor not mentioned earlier is that counterfeit drugs of all types are also common, and they are found not only in the private and illegal sectors, but in public sector facilities. In Senegal and Cambodia, the private sector dominates the provision of antimalarial drugs, but in Zambia, the public sector is the main source of care for malaria, including provision of drugs.
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agencies, the WHO-housed Special Programme for Research and Training in Tropical Diseases (WHO/TDR) has worked for the past 28 years to develop and promote the best use of pharmaceuticals and other malaria control measures.
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MVI works with other vaccine programs, vaccine development partners, and the Global Alliance for Vaccines and Immunization (GAVI) to explore commercialization, procurement, and delivery strategies that will maximize public health sector availability in the countries most affected by malaria.
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It aims to maximize the impact of scientific research against malaria in Africa, through promoting capacity building and facilitating global collaboration and coordination." http:// www.mim.su.se/english/about/index.html MIM was launched in 1997 following the first Pan-African Malaria Conference (Dakar, Senegal) , where researchers from all over the world identified important research priorities for future malaria research.
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, documented both achievements and "serious constraints" that threaten progress in phase 2, defined as mid-2002 to 2007. The accomplishments include raising the profile of malaria and increasing global funding -- funding for malaria control doubled in RBM's first 3 years.
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· 60% of those at risk for malaria, particularly children under 5 years of age and pregnant women, will benefit from a suitable combination of personal and community protective measures, such as ITNs Prevention and control of malaria · 60% of pregnant women at risk of in pregnant women malaria will be covered with suitable combinations of personal and community protective measures, such as ITNs · 60% of pregnant women at risk of malaria will have access to intermittent preventive treatment Malaria epidemic and emergency response · 60% of epidemics are detected within 2 weeks of onset · 60% of epidemics are responded to within 2 weeks of detection Note: The original Abuja declaration included the recommendation for chemoprophylaxis as well, but current WHO and RBM policy strongly recommends IPT -- and not chemoprophylaxis -- for prevention of malaria during pregnancy.
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The issues addressed by the IOM Committee on the Economics of Antimalarial Drugs are directly relevant to the MDGs, and should complement the work of the malaria subgroup of Task Force 5. The Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria (the "Global Fund")
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. This reflects the requests of countries to the Global Fund, which does not dictate how countries should approach malaria control.
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1996. Treatment practices for degedege, a locally recognized febrile illness, and implications for strategies to decrease mortality from severe malaria in Bagamoyo district, Tanzania.
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Presentation at the meeting of the 4th Global Partners Meeting, Washington, DC, April 18-19, 2001. Prepared by the National Malaria Control Programme, Ministry of Health, Kingdom of Cambodia.
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1996. Local terminology for febrile illnesses in Bagamoyo district, Tanzania and its impact on the design of a community-based malaria control programme.
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The district occupies 14,500 km2 and is entirely rural, with 94 registered villages. There are 57 formal health facilities: two hospitals (one government and one NGO)
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Of these deaths, 722 which fell under the following codings were suspected to be directly or indirectly due to malaria: · acute febrile illness 1-4 weeks · acute febrile illness 7days · acute febrile illness including malaria · acute febrile illness with seizures · acute febrile illness with anemia · cerebral malaria · fever plus malnutrition · malaria · malaria confirmed · unspecified acute febrile illness Among these 722, 45.8 percent were male, 54.2 percent female; 44.3 percent were under 5 years of age, 55.7 percent were 5 years or older; 39 (5.4 percent) had convulsions and possible cerebral malaria, while 94.6 percent reported no convulsions.
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Types of Care Sought The term modern care describes what conventionally includes biomedical, Western, pharmaceutical, professional, official, or formal health care. Traditional care describes what conventionally includes traditional medicine, traditional healers, traditional providers, lay providers, traditional practices, or folk care.
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· Of the group that had convulsions, 90 percent used modern care first, but only 63 percent continued with modern care for a second treatment. · Government health facilities and shopkeepers were the main source of antimalarial drugs.
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TEHIP is continuing to refine the information from this study, and will be analyzing the narrative portion of the verbal autopsy questionnaires to look at some specific aspects of the health care received, including: · delay in seeking modern care (e.g., tried to treat at home without antimalarials, no transport, beliefs, poor recognition of severity, lack of confidence in modern care, no power to decide, insufficient finances) ; · delay in receiving modern care (e.g., after working hours, weekends, long queues, satisfaction)
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