April 23, 2003
Africa Malaria Day, April 25, 2003 Malaria: The battle against resistance

Imagine a five-year-old girl living in a small village in sub-Saharan Africa. Feverish, she begins to shake and vomits up her breakfast. The girl's head hurts and she's getting weaker. She starts to cough and can't eat. Her mother takes her to a health post later that day and the doctor diagnoses malaria. She is given the drug chloroquine to take for three days. This happens to her maybe six times a year. Unfortunately, there is a good chance that the medicine she's been given doesn't even work due to drug resistance. Tragically, drugs do exist that can effectively treat malaria, but they are much more expensive than chloroquine, and their use is being blocked in many countries.

Advocating for more effective treatment

Doctors Without Borders/Médecins Sans Frontières (MSF) is now pushing endemic countries, donors, and those involved in malaria treatment to support the use of the most effective treatment for drug-resistant malaria, artemisinin-containing combination therapy (ACT), which is recommended by the World Health Organization. Older antimalarials such as chloroquine and sulfadoxine-pyrimethanmine (SP) no longer work in many parts of the world because of the development of resistance. Artemisinin has been used in Chinese traditional medicines for thousands of years. It has become a common treatment in Asia during the past 30 years where malaria resistance to older drugs is high. When used in combination with another drug, artemisinin derivatives appear to slow the development of resistance to the second drug. To date, no resistance to artemisinin drugs has been reported.

Malaria is spread by mosquitoes already infected with a parasite. When an infected mosquito bites a human, it transfers the parasite into the person's bloodstream, where it multiplies and causes illness or death. When another mosquito bites the person, the disease is passed along to others, and the cycle continues. Various attempts to eradicate the disease have failed and malaria remains a daily, deadly threat to 40% of the world's population. Approximately 300 to 500 million people contract the disease each year and one to two million die, many of them children. In fact, every 30 seconds, a child dies of malaria. Those that survive can experience stunted physical and mental development, poor education performance and greater susceptibility to other diseases.

In many areas of Africa, resistance levels to more common treatments are extreme. MSF teams have found chloroquine resistance rates of 78-85% in Bandundu, Democratic Republic of Congo and 87% in Mbarara, Uganda. But nowhere has resistance been higher than in Burundi which was struck by a major malaria epidemic in 2000-2001. MSF teams diagnosed and treated malaria in the hard-hit provinces of Kayanza, Ngozi, Karuzi, and Cankuzo and during a six-month period treated more than 1.2 million patients. The epidemic is estimated to have affected nearly three million people in Burundi and resulted in thousands of deaths. Those contracting malaria were treated with ineffective medicines-because chloroquine was Burundi's first-line treatment. "In parts of Africa, giving patients chloroquine is equivalent to giving them sugar pills," said Nicolas de Torrenté, executive director of MSF-USA.

During the course of the epidemic, MSF teams carried out several resistance studies and found that resistance to chloroquine in Burundi was as high as 90% in some areas, and resistance to SP was up to 63% in some regions. The World Health Organization recommends changing treatment protocols when resistance to first-line drugs reaches 25%. After strong advocacy efforts by MSF, the Burundi government decided in late 2002 to revise the national protocol so that ACT would be first-line treatment. This decision should take effect in July 2003. However, MSF is still watching the situation closely.

Overcoming barriers

Now integrating ACT into all of its medical projects, MSF is fighting to make better malaria treatments a priority at the international level by pushing for policy change and increased funding. In addition to Burundi, other countries are also planning to make ACT first-line therapy. A key barrier to switching to ACT is that it costs ten to twenty times as much as the currently used antimalarials. MSF estimates countries with high resistance to current malaria treatments (Burundi, Kenya, Rwanda, Tanzania and Uganda) would need to spend $19 million to change to ACT-a sum too high for them to pay without donor help.

Although there has been reluctance to support ACT from major international aid agencies including the US Agency for International Development (USAID), some donor organizations have signaled their support. Earlier this year, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced grants to Zambia and Zanzibar to implement ACT. "When Zambia first decided to change its national protocol to more effective malaria treatment, some donors opposed this more expensive choice," said Dr Jean-Marie Kindermans from MSF. With its decision to grant Zambia and Zanzibar money, the Global Fund has given a very positive sign that it endorses the use of more effective malaria treatment. By financing malaria treatment programs that include ACT, the Global Fund and other donors can play a crucial role in ensuring that all people who need it, including the poorest and most vulnerable, have access to effective malaria treatment.

But in the meantime, the clock is ticking. People who should be receiving good treatment are slipping away, one fever at a time.

Based on material written by Anastasia Warpinski, MSF International Office, that first appeared in the 2002 MSF International Activity Report.

© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)