Strong words against oral artemisinin monotherapy drugs

Forty-four Ministers of Health of the African continent (as well as Brazil and India) or their representatives congregated at a special ministerial session of the 18th Roll Back Malaria (RBM) Partnership Board meeting and on the last day, 14th May 2010, signed a document in which they, “Express(ed) our governments’ engagement, with support from our development partners, to eliminate (ban and enforce) oral artemisinin-based malaria monotherapies and substandard ACTs from the market through tangible policies, strategies and regulatory measure within the next 12 months.” Hopefully these words will lead to action and soon.

art_drugs_sm.JPGThe World Health Organization has been pressing this issue strongly for several years, and as far back as 2001 a WHO publication, “Use of Antimalarial Drugs” (pg. 72), specifically stated that artemisinin should preferably be administered in combination with another effective blood schizonticide. A press release in early 2006 WHO called for an immediate halt to provision of single-drug artemisinin malaria pills, and was issued in concert new malaria treatment guidelines issued by WHO.  In another press release later in 2006 WHO announced that some pharmaceutical companies agreed to stop marketing single-drug artemisinin malaria pills, specifically the press release explained that …

“In January 2006, WHO appealed to all companies to stop marketing oral artemisinin monotherapies and to re-direct their production efforts towards ACTs. Following the January appeal, an additional 23 companies were identified and informed of WHO’s recommendation. 13 companies said they would comply with the WHO guidance. Additional companies have said they are willing to collaborate with WHO in this endeavour.”

It is not clear that WHO’s warning was heeded, because another WHO press release on 25 February 2009 stated that, “WHO today said that the emergence of parasites resistant to artemisinin at the Thai-Cambodia border could seriously undermine the success of the global malaria control efforts.” While outright resistance was not declared, Dondorp and colleagues found in 2009 that, “P. falciparum has reduced in vivo susceptibility to artesunate in western Cambodia.”

Reuters reported earlier this year that, “Pailin (Cambodia) is the origin of three drug-resistant malaria parasites over the past five decades. Thanks to prolonged civil conflict, dense jungles and movement of mass migrants in the gem mines in the 1980s and 90s, the strains multiplied and dispersed through Myanmar, India and two eventually reached Africa.” The situation is made worse by illegal pharmacies that sell counterfeit medicines. MediaGlobal stated earlier this month that, “the government (of Cambodia) has shut down 65 percent of illegal pharmacies. The number of illegal pharmacies has decreased from 1,081 in November 2009 to 379 in March 2010.”

Action by the 44 African Ministers of Health is not too late, but it could have come sooner. The Ministers pledged to “Report on progress in eliminating oral artemisinin-based monotherapies in May 2011,” as they signed up “to the commitment against the use of oral artemisinin-based monotheraples for malaria control.”

Nigeria, with the highest malaria burden in Africa, was one of the countries that apparently missed the meeting. Onwujekwe and co-researchers recently documented the sales or provision of monotherapy artesunate drugs in most of the public and private hospitals as well as pharmacies they studied in Anambra State. Nigeria’s policy concerning monotherapy artemisinin drugs was to all those already on the market to continue until their license ran out.

As we reported previously, some of those licenses will not expire until 2012.  We hope Nigeria and all other malaria endemic countries will act sooner than later and be able to report the complete removal of monotherapy artemisinin drugs my May 2011.  We want to eliminate malaria, not eliminate the effectiveness of ACTs.

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