The World Health Organization (WHO) this week recommended a change in the first-line treatment for malaria that could save nearly 200,000 lives a year, but health activists in Africa are bracing themselves for a potentially long battle in getting the new guidelines implemented.
Most cases of malaria are uncomplicated and non-fatal, particularly when patients have been exposed to the parasite and developed an immune response to it, but about eight million cases a year progress to “severe” malaria, which resulted in 781,000 deaths in 2009. Ninety percent of those occurred in Africa, where the disease is the leading cause of death in children.
Quinine has been the drug of choice for treating severe malaria for years, but it is difficult to administer and can have dangerous side effects.
"It requires a lot of calculation," said Veronique De Clerk, medical coordinator for international NGO, Médecins Sans Frontières in the northern Ugandan district of Kaabong. "You need to dilute it into infusions, and those infusions need to run through an IV [intravenous line] for four hours [every eight hours], and you need to monitor that, so it requires well-qualified personnel."
In rural Africa, where health workers are in short supply, it was common for patients to receive too much or too little quinine, with results that could be deadly, said De Clerk. "Recently, some studies from Uganda showed one in four administrations of quinine weren't correct."
WHO has recommended artesunate for severe malaria in adults since 2006, but this week revised its guidelines to include children, based on findings from a nine-country trial in Africa in 2010, which found that for every 41 children treated with artesunate instead of quinine, one life could be saved.
"It's very rare you have such a clear benefit of one drug over another, especially in neglected diseases like malaria," commented Nathan Ford, medical coordinator for MSF's Campaign for Access to Essential Medicines.
Several large clinical trials in the last decade have demonstrated that artesunate is safer, easier to use and more effective than quinine. It can be administered over three days either intravenously or through a daily intramuscular injection, meaning that non-medical personnel could be trained to provide the drug, bringing life-saving treatment closer to remote, rural communities.
|It's very rare you have such a clear benefit of one drug over another, especially in neglected diseases like malaria|
This week, MSF released a report, Making the Switch, which lists the benefits of treatment with artesunate rather than quinine, and the challenges in translating this evidence into policy and practice.
The biggest barrier is that artesunate costs two or three times more than quinine - around US$3.30 to treat one child compared to $1.3 for quinine - with additional costs for training health workers to administer it.
"Any change in protocol which results in an increase in cost is going to be a challenge in countries where health budgets are over-stretched," Ford told IRIN. MSF put the additional annual cost of treating severe malaria globally with artesunate at $31 million.
Ford said international donors could absorb this amount fairly easily, but had not traditionally supported the cost of treating severe malaria and would be unlikely to offer support until governments took the lead by changing their national guidelines.
"The WHO guidelines are just the first step," he told IRIN. "[They] need to be translated into national and local guidelines and protocols, with adequate training."
WHO recommended abandoning the use of chloroqine as the standard treatment for malaria a decade ago, but health professionals in some African countries still prescribe it. "It's a matter of changing long-term habits and practices," Ford commented.
De Clerk noted that although Uganda's national guidelines listed artesunate as an alternative to quinine, in reality the drug was unavailable. "For government, the price is important, and quinine has a very long shelf-life, so they'd want to get rid of those stocks first," she said.
WHO has prequalified only one manufacturer to produce artesunate, but MSF hoped that rising demand would encourage more manufacturers to enter the market, improving supply and reducing the price, and making long-term donor support unnecessary.
In the meantime, said Ford, "what we want is a very clear message from donors to say that any country switching [to artesunate] will be supported by us to cover the increased costs in the short term."