Lack of adherence to the full course of Artemisinin-based combination therapy (ACT) treatment is threatening the effectiveness of the drug recommended as first-line treatment for uncomplicated malaria in countries where the disease is endemic, according to recent studies.
In Siaya district of western Kenya, where malaria is particularly prevalent (38 percent incidence in 2010), a study revealed that only 47 percent of participants reported completing the given doses.
“There have always been concerns about whether patients are fully adhering to their treatment regimens once they receive the recommended Artemisinin-based combination therapy. Our study reveals that adherence is poor among many patients,” Eric Onyango, lead researcher, told IRIN.
The study investigated ACT adherence levels, factors associated with non-adherence and household access to ACT. It involved 297 participants, all of whom had tested positive to Plasmodium falciparum, the parasite responsible for causing malaria, at the time of the study. A household’s education level was found to be the highest predictor of poor adherence. Others included household income and age.
Another study carried out in five outpatient government health clinics in two Kenyan districts, all with high malaria prevalence, concluded that while 64.1 percent of the 918 patients included in the study were probably adherent, the rate was lower than that of previous studies.
The authors concluded that “targeted information, education and communication activities at the community level may help to increase awareness of the treatment regimen and its uptake, and reduce the risk of contributing to the development of parasite resistance”.
According to health experts, proper adherence to malaria treatment drugs is important in improving treatment outcomes, reducing cases of drug resistant malaria and controlling the disease.
“People who have malaria infection should always be diagnosed in good time and put on treatment early. If they fail to adhere to their treatment, there could be increased cases of drug-resistant malaria, which affects better treatment outcomes and the management of the disease,” Andrew Sulleh, a doctor, told IRIN.
“People are likely to adhere when they seek treatment early. This means it is important that they are educated on the symptoms of possible malarial infection so that they are able to seek early diagnosis and treatment,” he said.
In 2010, malaria caused 655,000 deaths, many of them in Africa, where the disease accounts for 22 percent of all childhood deaths, according to the World Health Organization (WHO).
Many malaria-endemic countries in Africa have switched to ACT, after malaria parasites developed resistance to mono-therapies. The WHO estimates that in 2010 alone, some 181 million courses of ACT were procured worldwide in the public sector.
While some earlier studies done soon after the roll-out of ACT have shown high prevalence –change to - adherence rates of up to 75 percent, health workers say the high number of tablets involved in ACT regimens to complete a full three-day dose could be contributing to poor adherence. Adult patients are expected to take eight tablets a day within eight hours for three days, while children take four tablets daily within a similar period.
“The tablets that a patient is expected to take daily are very many and they are unpalatable and this makes others just take the medicine for a short time and throw away the rest. Some also feel they are fine after taking a few tablets and stop their medication halfway,” said Lillian Natembea, a nursing officer at the Kenyatta National Hospital, Kenya’s largest referral facility.
In a small study in rural Ethiopia, 37.3 percent of the patients who were reported as definitely non-adherent blamed the many tablets, while another 25 percent said they did not continue because they felt better before finishing the dose.
Health officials say patient education and counseling are important in ensuring adherence to ACT regimens.
“What happens at the time of the interaction between the patient and the healthcare worker is important in maintaining adherence. Health workers need to counsel and educate patients on how to take the drugs and on the importance of completing their doses,” said Sulleh, who is also head of the Mbagathi District Hospital in Nairobi.
According to Elizabeth Juma, head of malaria control at Kenya’s Ministry of Public Health, proper malaria treatment is as important as malaria prevention, saying strategies such as the use of insecticide treated mosquito nets should be promoted.
“Proper treatment for those already infected with malaria is important, but even more important is the promotion of prevention strategies like the use of insecticide treated nets, which is still low in the country,” she said.
The Kenya Malaria Indicator Survey 2010 shows that while 48 percent of Kenyan households own at least one insecticide treated mosquito net, just 32 percent use it.