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Date: Fri, 22 Feb 2002 09:48:44 -0500
From: Africa Action <[log in to unmask]>
To: [log in to unmask]
Subject: Africa: Malaria Treatment
Africa: Malaria Treatment
Date distributed (ymd): 020222
Document reposted by Africa Action
Africa Policy Electronic Distribution List: an information
service provided by AFRICA ACTION (incorporating the Africa
Policy Information Center, The Africa Fund, and the American
Committee on Africa). Find more information for action for
Africa at http://www.africaaction.org
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Region: Continent-Wide
Issue Areas: +economy/development+ +health+
SUMMARY CONTENTS:
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
+++++++++++++++++end profile++++++++++++++++++++++++++++++
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.
Treatment
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.
************************************************************
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