Urgent Action Essential to Protect Malaria Therapies, Says WHO

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The world risks losing its most potent treatment for malaria unless steps are quickly taken to prevent the development and spread of drug resistant parasites, according to a new action plan released today by WHO and Roll Back Malaria partnership (RBM).

The Global plan for artemisinin resistance containment outlines the necessary actions to contain and prevent resistance to artemisinins, which are the critical component of artemisinin-based combination therapies (ACTs), the most potent weapon in treating falciparum malaria, the deadliest form of the disease. Resistance to artemisinins has already emerged in areas on the Cambodia-Thailand border. Although ACTs are currently more than 90% efficacious around the world, quick action is essential. If these treatments fail, many countries will have nothing to fall back on.

Stop the emergence of drug resistance at its source

“The usefulness of our most potent weapon in treating malaria is now under threat,” said Dr Margaret Chan, WHO Director-General. “The new plan takes advantage of an unprecedented opportunity in the history of malaria control: to stop the emergence of drug resistance at its source and prevent further international spread. The consequences of widespread artemisinin resistance compel us to seize this opportunity.”

The global plan aims to contain and prevent artemisinin resistance through a five-step action plan:

1. Stop the spread of resistant parasites

A fully funded and implemented malaria control agenda, as outlined in the Global malaria action plan, would address many of the needs for the containment and prevention of artemisinin resistance. However, additional funding will be needed to stop the spread of resistant parasites in areas where there is evidence of artemisinin resistance. The global plan estimates that it will cost an additional US$ 10–20 per person in areas of confirmed resistance (Cambodia-Thailand border) and US$ 8–10 per person in the at-risk areas of the Greater Mekong area.

2. Increase monitoring and surveillance for artemisinin resistance

WHO estimated in 2010 that only 31 of the 75 countries that should be conducting routine testing of the efficacy of ACTs actually did so. There is a risk of artemisinin resistance emerging silently in areas without ongoing surveillance.

3. Improve access to malaria diagnostic testing and rational treatment with ACTs

These therapies are frequently used to treat causes of fever other than malaria. Unnecessary use of ACTs can increase the risk of resistance. In order to reduce the number of patients who do not have malaria taking the therapies, WHO recommends diagnostic testing of all suspected malaria cases prior to treatment.

4. Invest in artemisinin resistance-related research

There is an urgent need to develop more rapid techniques for detecting resistant parasites, and to develop new classes of antimalarial medicines to eventually replace the ACTs.

5. Motivate action and mobilize resources

The success of the global plan will depend on a well-coordinated and adequately funded response from many stakeholders at global, regional and national levels.

”Effective containment of artemisinin resistance will significantly improve our capability to sustain current control achievements at country level,” said Professor Awa Coll-Seck, Executive Director of the Roll Back Malaria Partnership. ”We now have a coordinated plan to stop the spread of resistant parasites, but we need additional funding to fully implement it,” Coll-Seck reminded the international donor community.

WHO estimates that the number of malaria cases has fallen by more than 50% in 43 countries over the past decade. A recent modeling analysis of malaria prevention in 34 African countries estimates that more than 730 000 lives were saved between 2000 and 2010; nearly three quarters of them since 2006, when the use of both insecticide treated mosquito nets and ACTs became more widespread. The loss of ACTs as an effective treatment would likely result in a significant increase in malaria-related deaths.

Tremendous progress against malaria

“We have made tremendous progress over the past decade in the fight against malaria,” noted Dr Robert Newman, Director of the WHO Global Malaria Programme. “If we are to sustain these gains and achieve the health-related Millennium Development Goals, then it is essential that we work together to overcome the threat of artemisinin resistance.”

The Global plan for artemisinin resistance containment was developed by the WHO Global Malaria Programme through consultation with over 100 malaria experts from across the Roll Back Malaria Partnership. Funding was provided by the Bill & Melinda Gates Foundation.

Source: WHO

WHO’s World Malaria Report Shows Rapid Progress Toward Targets

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A massive scale-up in malaria control programmes between 2008 and 2010 has resulted in the provision of enough insecticide-treated mosquito nets (ITNs) to protect more than 578 million people at risk of malaria in sub-Saharan Africa.

Indoor residual spraying has also protected 75 million people, or 10% of the population at risk in 2009. The World Malaria Report 2010 describes how the drive to provide access to antimalarial interventions to all those who need them, called for by the UN Secretary-General in 2008, is producing results.

Downward trend in malaria

In Africa, a total of 11 countries showed a greater than 50% reduction in either confirmed malaria cases or malaria admissions and deaths over the past decade. A decrease of more than 50% in the number of confirmed cases of malaria was also found in 32 of the 56 malaria-endemic countries outside Africa during this same time period, while downward trends of 25%–50% were seen in eight additional countries. Morocco and Turkmenistan were certified by the Director-General of WHO in 2009 as having eliminated malaria. In 2009, the WHO European Region reported no cases of Plasmodium falciparum malaria for the first time.

Results: the best in decades

The WHO Director-General, Dr Margaret Chan, highlighted the transformation that is taking place, “The results set out in this report are the best seen in decades. After so many years of deterioration and stagnation in the malaria situation, countries and their development partners are now on the offensive. Current strategies work.”

“The phenomenal expansion in access to malaria control interventions is translating directly into lives saved, as the WHO World malaria report 2010 clearly indicates,” said Ray Chambers, the UN Secretary-General’s Special Envoy for Malaria. “The strategic scale-up that is eroding malaria’s influence is a critical step in the effort to combat poverty-related health threats. By maintaining these essential gains, we can end malaria deaths by 2015.”

Strategies to fight malaria

The strategies to fight malaria continue to evolve. Earlier this year, WHO recommended that all suspected cases of malaria be confirmed by a diagnostic test before antimalarial drugs are administered. It is no longer appropriate to assume that every person with a fever has malaria and needs antimalarial treatment. Inexpensive, quality-assured rapid diagnostic tests are now available that can be used by all health care workers, including at peripheral health facilities and at the community level. Using these tests improves the quality of care for individual patients, cuts down the over-prescribing of artemisinin-based combination therapies (ACTs) and guards against the spread of resistance to these medicines.

Fragility of malaria control

While progress in reducing the burden of malaria has been remarkable, resurgences in cases were observed in parts of at least three African countries (Rwanda, Sao Tome and Principe, and Zambia). The reasons for these resurgences are not known with certainty but illustrate the fragility of malaria control and the need to maintain intervention coverage even if numbers of cases have been reduced substantially.

Work remains to attain targets

The report stressed that while considerable progress has been made, much work remains in order to attain international targets for malaria control.

  • Financial disbursements reached their highest ever levels in 2009 at US$ 1.5 billion, but new commitments for malaria control appear to have levelled-off in 2010, at US$ 1.8 billion. The amounts committed to malaria, while substantial, still fall short of the resources required for malaria control, estimated at more than US$ 6 billion for the year 2010.
  • In 2010, more African households (42%) owned at least one ITN, and more children under five years of age were using an ITN (35%) compared to previous years. Household ITN ownership reached more than 50% in 19 African countries. The percentage of children using ITNs is still below the World Health Assembly target of 80% partly because up to the end of 2009, ITN ownership remained low in some of the largest African countries.
  • The proportion of reported cases in Africa confirmed with a diagnostic test has risen substantially from less than 5% at the beginning of the decade to approximately 35% in 2009, but low rates persist in the majority of African countries and in a minority of countries in other regions.
  • By the end of 2009, 11 African countries were providing sufficient courses of ACTs to cover more than 100% of malaria cases seen in the public sector; a further 5 African countries delivered sufficient courses to treat 50%–100% of cases. These figures represent a substantial increase since 2005, when only five countries were providing sufficient courses of ACT to cover more than 50% of patients treated in the public sector.
  • The number of deaths due to malaria is estimated to have decreased from 985 000 in 2000 to 781 000 in 2009. Decreases in malaria deaths have been observed in all WHO regions, with the largest proportional decreases noted in the European Region, followed by the Region of the Americas. The largest absolute decreases in deaths were observed in Africa.

In summary, the report highlights the importance of maintaining the momentum for malaria prevention, control, and elimination that has developed over the past decade. While the significant recent gains are fragile, they must be sustained. It is critical that the international community ensure sufficient and predictable funding to meet the ambitious targets set for malaria control as part of the drive to reach the health-related Millennium Development Goals by 2015.

Full Report:  World Malaria Report 2010

Source: World Health Organization (WHO)