Preventing drug resistance in malaria treatment

With drug resistance emerging as a problem in Thailand’s borders with Myanmar and Cambodia, APPOLONI A ADEYEMI reports that urgent measures must be taken to avert it in Nigeria

 

 

The last 11 months were traumatic for 14-year-old Tade Malaika (not real name) who had been in and out of hospital admission for three consecutive times. The case of Ekaete Joseph, 35, who was similarly down with fever was different. Much as he suffered the fever, she resorted to self-medication, purchasing malaria medications from patent-medicine stores.

Efforts to persuade her go through a laboratory test to determine if the ailment was truly malaria failed as she could not afford the cost of N1000 test. Sadly, her condition went from bad to worse and four months afterwards, she passed on.

The case of Joseph is typical of what many Nigerians go through today in view of the prevailing economic situation, which makes it difficult for many poor and low income Nigerians to afford to pay for laboratory tests to ensure that the medical condition they are treating is actually malaria.

Bringing these to the front burner has become imperative against the background of the 2017 World Malaria Day, marked globally on April 25 to highlight the burden of malaria.

This year’s theme is “End Malaria For Good”. According to the World Health Organisation, WHO, malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes.

Usually found in tropical and subtropical climates where the parasites that cause it live, one thing about the disease is that it can be transferred from an infected pregnant mother to her baby at birth.

Unfortunately, it remains both a major cause and a consequence of global poverty and inequity. Its burden is greatest in developing countries like Nigeria and among the poorest members of the society.

The WHO recommends prompt malaria diagnosis either by microscopy or malaria rapid diagnostic test (RDT) in all patients with suspected malaria before treatment is administered.

Diagnostic testing improves the overall management of patients with febrile illnesses, and may also help to reduce the emergence and spread of drug resistance by reserving anti-malarials for those who actually have the disease.

The problem however, is that not many people do the test before administering ante-malaria drugs, most of which is self-medication. Experts said these could result to drug resistance on the long run. Approximately 40 per cent of the total global population is at risk of malaria infection. Sub-Saharan Africa carries a disproportionately high share of the global malaria burden.

In 2015, the region was home to 90 per cent of malaria cases and 92 per cent of malaria deaths. About 80 per cent of all malaria cases occur in just 17 countries. Nigeria and the Democratic Republic of the Congo (DRC) account for more than 40 per cent of all malaria deaths worldwide.

In Nigeria, data from the Federal Ministry of Health (FMOH) shows that malaria accounts for 60 per cent of outpatient visits and 30 per cent of hospitalisations among children under-five years of age. With a population of 174.5 million people, WHO estimates that onequarter of all malaria cases in Africa occurs in Nigeria.

Speaking on measures to avertdrug resistance in malaria attack, the Lagos State Commissioner for Health, Dr Jide Idris, a public health physician, said resistant malaria was related to resistance to drugs used to treat the disease.

He said: “The resistance has to do with the quality of drug itself. Does the drug contain the right dose?” Researchers from the Fogarty Interna- tional Centre at the National Institute of Health in Bethesda, Maryland, the United States of America (USA), reported in The Lancet Infectious Diseases (May 2012 is- sue) that up to 42 per cent of anti-malarial medications available across sub-Saharan Africa and Southeast Asia are either fake or substandard.

Co-author, Dr. Joel Breman, Senior Sci- entist Emeritus said, “Poor quality anti- malarial drugs are very likely to jeopardise the unprecedented progress and investments in control and elimination of malaria made in the past decade.”

Scientific evidence shows that fake or substandard anti-malarial mediations do not have active ingredients and can encour- age the development of resistant strains of malaria parasite.

Although the National Agency for Food and Drug Administration and Control (NAFDAC) has introduced a text messaging system and other devices that help to determine fake drugs at the point of purchase. The use of such facilities will help consumers and healthcare providers go for genuine drugs.

Highlighting another major cause of drug resistance in malaria, Idris said it was also important for patients to comply with malaria medications as prescribed. According to the commissioner, in this environment, once a lot of people discover they have fever, they start taking drugs. If the fever relieves them, they stop the drugs.

“These are major causes of drug resistance,” he noted, adding that malaria parasite in the blood is also a living organism, reacting, and finding a way, too to counter those drugs.

Idris lamented that many Nigerians contribute to why malaria parasites resist prescribed drugs. Malaria parasite is capable of becoming resistant to the action of antimalaria drugs.

This is due to small changes in the parasite DNA (point mutations). Over-prescription of antimalarial (confusion with other febrile diseases) and the uncontrolled selling of poor quality drugs contribute to the increase in drug resistant parasites.

The widespread and increasing occurrence of P. falciparum resistance against affordable anti-malarial drugs, such as chloroquine (CQ) and sulphadoxine- pyrimethamine (SP) is more and more hampering the fight against malaria. CQ and SP are still the most widely used drugs for malaria treatment in most of Africa, because of low cost and availability.

At present, WHO recommends that all countries experiencing resistance to conventional mono-therapies, such as chloroquine or sulfadoxine-pyrimethamine, should use combination therapies, preferably artemisininbased combination therapies (ACTs) for P. falciparum malaria. Artemisinin-based combination therapy (ACT) uses a combination of anti-malaria drugs, one of which is an artemisinin derivative (e.g. artesunate, artemether or dihydroartemisinin).

However, Idris said that despite the policy change, “some of our people are still using single dose monotherapies as as chloroquine. All these things contribute to drug resistance”.

He added that individuals should take responsibility for their own health. The artemesinin family of drugs is the world’s front-line defense against the most prevalent and deadly form of malaria, WHO warned in 2006.

The former National President of the Association of Community Pharmacists of Nigeria (ACPN), Olufemi Ismail Adebayo, said “it does not take time to do the rapid diagnostic test, RDT”. Adebayo urged patients to seek care from appropriate healthcare providers and not because they have headache, begin to treat malaria. He said: “Headache could be a symptom of so many other ailments.

People should get drugs dispensed from a pharmacist so as to get appropriate counsel- ling. When seeking treatment, do not go to quarks. “Also, ensure that you do not default in taking your medication.

If you take prescribed drugs halfway and do not complete it, it may lead to drug resistance. “When this happens, when next you take the drug, it will not work. You have to seek a more effective drug.”

Sadly, what is experienced in Nigeria is that many low income and poor people who present with fever and other malaria symptoms resort to self-medication. Specialised drugs that are not grouped under over-the-counter (OCT) medications are freely prescribed by non-medical professionals who oversee patent-medicine stores/drug stores.

Laymen selling drugs from such stores even go as far as administering injections to patients. Adebayo said many drug stores and pharmacies in private health facilities are not manned by pharmacists, giving room to unqualifiied personnel dispensing drugs without necessary professional counselling that should go with the practice.

It is also known that some healthcare workers like nurses, laboratory scientists, and others not only prescribe but dispense malaria drugs. Adebayo described these as malpractice which should be stopped to check quackery. According to Adebayo, drugs are poisons. They should be taken only when they are needed and for the number of days prescribed.

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