Artemisinin – production, resistance, change

The fate of artemisinin in malaria control may be affected from the plant source to the parasites in humans according to two recent web postings.  Some challenges may result from people willing to change quickly, while others may be slow to react.

Sociolingo Africa has provided an update on artemisinin production in Uganda.  The situation of decreasing prices amid increasing demand was seen as puzzling.  The farmers who had begun cash crop production of artemisinin were now seeing ‘leaves rotting in the fields’ and were being encouraged to grow “Davana; Chillies; Fennel; Jasmine Rose; Ginger; Vettiver; Basil; and many more others, most of which are used in the production of essential oils and perfumes” by the Indian companies that were in fact guiding the Ugandan production of artemisinin.

It is possible, considering any commodity market, that diversification is a wise move on the part of the company.  Clearly there are efforts afoot (e.g. AMFm, Clinton Foundation) to reduce to cost that consumers pay in order to make the artemisinin-based combination therapy (ACT) drugs available thus, creating possibly more downward pressure on pricing.

In the early days of ACT promotion prices of the drug were said to be high because of the uncertainties in the procurement processes of endemic countries.  International mechanisms by organizations such as the Global Fund and WHO to coordinate this process while also increasing the supply to reach coverage targets also mean that production could confidently increase while prices of the final product could reduce.

So back to Uganda – there is likely now greater competition among producers of artemisinin in many countries – including the Ugandan farmers – in line with increasing demand projections. These farmers changed in reponse to the companies’ projections. At least in this case if substitute crops are provided, they may not suffer too much, but the fate of such farmers in other endemic countries such as Kenya where artemisinin farming has been introduced may not be so clear.

On the other side of the continent there are worries about parasite resistance to artemisinin.  In Nigeria ASNS News notes that, “Dr. Paul Orhi, Director General of NAFDAC (National Agency for Food and Drug Administration and Control), is quoted in the local press that the main reason for (growing emergence of resistance) was because people were not taking proper doses and that they still use monotherapy instead of combining two drugs appropriately.”

While it may take time for the resistance to spread from Southeast Asia where it has recently been documented, the Nigerian concern is real.  The irony is that there does not need to be worry about monotherapy if NAFDAC were to be bold and withdraw the registration of the numerous artesunate monotherapies currently on the market in Nigeria.

The current policy of NAFDAC is to allow those monotherapy drugs already registered to stay on the market until their registrations expire – some as late as 2012.  If NAFDAC were bold enough to change now and withdraw those registrations, its Director General would have less to worry about.  Proper training of health and pharmacy workers in both public, private and commercial sectors to counsel those receiving ACTs on the proper regimen would also reduce his worry about improper dosing.

Timely and appropriate change is needed to protect and increase the malaria drug supplies we have now, while research continues to find new medicines as the need will most certainly arise.

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