Tropical Health Matters

Last week Dora Akunyili, Director General of Nigeria’s National Agency for Food and Drug Administration (NAFDAC) called on faith based organizations to join the fight against counterfeit malaria drugs in Nigeria. She explained that with the faded efficacy of chloroquine and sulfadoxine-pyrimethamine (SP) Nigeria must be vigilant in protecting the efficacy of ACTs.

NAFDAC does take action as seen in a recent newspaper notice seen in part here that warns the public about unregistered and potentially dangerous drugs. NAFDAC has taken other recent helpful actions. For example, the Agency has asked producers of SP to remove the warning that this drug is contraindicated in pregnancy so that SP can be used for IPTp during the second and third trimesters (but still not the first).

Some challenges remain. Many monotherapy artesunate drugs had been registered over the past 5 years, and although NAFDAC agrees with WHO that such drugs can lead to resistance and should not be sold, NAFDAC has taken a more conservative approach and is simply allowing the licenses on those products to expire. The monotherapy drugs are still in abundance in the medicine and pharmacy shops, particularly in urban areas, and some state pharmacy stores do stock them. While it would mean financial loss to companies, businesses and clinics if monotherapy artemisinin drugs were abruptly withdrawn, the longer term costs of developing resistance to artemisinin-based drugs would be enormous both in terms of lives and finance.

Nigeria is not the only country that should pay attention to its malaria drug supply. Recently I purchased an artesunate-SP combination in a registered pharmacy shop in Entebbe, Uganda as seen in the photo. Again, combinations of artesunate and drugs like chloroquine and SP that have reduced efficacy is dangerous in terms of speeding up development of parasite resistance to the artesunates. WHO expects that this combination “will fail rapidly.”

The time to act to protect ACTs in Africa in now.

[Note that photos of pharmaceutical products do NOT constitute an endorsement.]

Ghana, like other countries in the region, is reported to be revising its national malaria strategy. Most countries developed a new strategy document around 2001, at the beginning of the Roll Back Malaria Partnership, that reflected the goals of achieving 60% coverage of the core interventions (ITNs, IPT and appropriate and timely case management).  This level was supposed to have been achieved by 2005, and then new targets of 80% coverage took effect for the 5-year period starting 2006.  Many changes occurred between 2001 and 2006 including the availability of artemisinin-based combination therapy (ACT), long-lasting insecticide treated nets (LLINs), and the re-emergence of indoor residual spraying (IRS).

Some shifts in policy have occurred, and it is natural for a new strategy to be developed to account for these. The Global Fund for Fighting AIDS, TB and Malaria (GFATM) noted that Ghana switched to ACTs, and now the country needs to embody this in their malaria strategy. Ghana was given permission to use artesunate-amodiaquine as its ACT rather than the pre-qualified drug artemether-lumefantrine.  Drug quality issues resulted in serious side effects that eroded the public trust. The Food and Drugs Board took action, and as the GFATM noted, the PR worked hard “to overcome the bad publicity around the launch of ACTs.” Therefore the new malaria strategy needs a strong health education component to overcome and remaining public skepticism about the intentions and quality of the national malaria control effort.

Another challenge of the new malaria strategy will be to prevent the diversion of nets into the private sector. This problem likely arose in part due to the fact that cost was a major issue that prohibited net ownership before the start of the GFATM grant.

Ghana is also considering IRS, which is possible now that Ghana has been designated a PMI country. The challenge with IRS is determining the appropriate insecticide because of varying resistance of vectors in different regions of the country.

Overall the biggest challenge in revising the malaria strategy is determining Ghana’s own national malaria control needs and then coordinating the input of donors to meet those needs rather than developing a strategy based solely on what the donors expect.

A few hours ago the Associated Press reported from a meeting in Paris that leading scientists from 113 countries agreed, that “global warming has begun, is ‘very likely’ caused by man, and will be unstoppable for centuries.”  Their 20-page report will be available soon.  “Very likely” was translated statistically as 90%. The panel of scientists was created by the United Nations in 1988 and has been reporting every 5-6 years.

Malaria as a disease is quite climate dependent.  Altitude and temperature are factors. Reports from highland areas of Africa indicate that changes in weather patterns, such as the El Niño, mean that, “these areas will experience more epidemics as a result of global warming” according to Koenraadt et al. (2006). This is supported by the Roll Back Malaria Partnership/WHO in their publication on malaria epidemics: “It is now better documented that important malaria epidemics in certain locales have been linked to El Niño/La Niña unusual events (the cyclical El Niño Southern Oscillation – ENSO phenomenon), which may lead to better prediction in terms of the magnitude of malaria epidemics and their health implications.”  For example, Ayamba et al. (2006) discussed the implications of El Niño conditions heating the ocean waters of the tropical Pacific Ocean during 2006-07 would lead to, “Increased risk for RVF (Rift Valley Fever) and malaria resulting from elevated mosquito vector populations, and cholera caused by flooding due to heavy rainfall in dry land areas.”

Patz and Olson (2006) indicate that a little temperature change can become a lot of mosquitoes: “Those who argue that we need not worry about small shifts in temperature should pause after considering the findings of Pascual et al. that a mere half-degree centigrade increase in temperature trend can translate into a 30–100% increase in mosquito abundance, in other words ‘biological amplification’ of temperature effects.”

Earlier this year, the Harben Lecture, printed simultaneously by The Lancet and Public Health, looked at the evidence for climate change induced disease pattern changes. More so, they expressed concern about the ability of malaria control programs to cope: “It is likely that additional populations put at risk by climate change will be in low-income countries, since it is generally assumed that more developed countries, which currently control malaria, will remain able to do so. Malaria in poorer countries is currently only restricted by climate factors in specific arid and highland regions. The ability of these countries to manage any climate-induced increase in malaria will depend on their capacity to develop and sustain malaria control programmes.” (Haines et al., 2006)  This is the crux of the matter – vulnerable populations are still vulnerable unless major progress is made in terms of health system reform, which in turn will be jeopardized if climate effects on agriculture and economic development also reduce the ability of countries to progress.

The Associated Press reports “a 40 percent increase, to $4.5 billion, for fighting AIDS, malaria and tuberculosis overseas” from the new US Congress.  This was especially amazing given both the stiff competition among various programs, as well as what the AP observed to be strong efforts to control spending on special projects known as earmarks.

A special thanks is due to the many agencies and NGOs who joined hands for advocacy to promote a malaria free future. their letter to Congress made a difference. There are strong indications that this spending bill will be signed by the President, enabling the President’s Malaria Initiative to actually take off with its own funding.