Ghana Confronts Chloroquine

The Ghanaian Chronical this week quotes a district medical office’s concerns “about the continuous sale of chloroquine at chemical shops and urged the Ghana Standard Board to intensify its activities to withdraw the chloroquine from the shops since it would negatively affect the new drug policy,” which lists artesunate-amodiaquine as its first line antimalarial drug. This is backed by research that shows Plasmodium falciparum is highly resistant to chloroquine in Ghana. The question arises whether it is feasible to ban chloroquine.

Nigeria has also gone through a change of malaria drug policy dropping chloroquine as the first line drug and substituting artemether-lumefantrine (AL).  When this happened, the press and the public assumed that a ban on chloroquine would soon follow, but this did not happen. To date chloroquine has not been banned, but efforts have been made to increase the supply of the new artemisinin-based combination therapy drug AL through support from donors like the Global Fund. The reality is that it takes time to transition to new malaria drugs, and when supplies of the more expensive ACTs are not yet available throughout the country, it would be irresponsible to ban other products.

A better approach than banning products is combining donor and national support to acquire adequate ACT supplies with education of both the public and health care providers (public and private) on the benefits of the new drugs. If adequate supplies of free ACTs are available, at least for children under five years of age, demand for chloroquine will naturally decline.

On the demand side, WHO has stressed the importance of educating the public on judicious use of antimicrobial drugs to prevent resistance, and also recommended that. “Education programmes must also be tailored to the needs of specific groups – be they village healers, market vendors, street dispensers, health care workers, paramedical assistants, midwives, nurses, dentists, doctors or others involved in primary care.” Hopefully the two-pronged approach of supply and demand will help countries like Ghana confront their chloroquine challenge.

PS: We shared recently findings from Malawi that after withdrawal of chloroquine in 1993, malaria parasites are again showing susceptibility to chloroquine.  The same experience may occur in Ghana and other West Africa countries in another 10 or more years if ACTs become not only the official policy but the only drugs that are actually demanded and prescribed. A work of caution is needed though. Juliano used new techniques to identify previously undetectable genetic evidence of continued chloroquine resistance in Malawi. This reinforces the importance of combination therapy as the only way forward in the future of malaria control.

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