Current National Drug Policies in Lao P.D.R. By Dr Samlane Phompida Centre of Malariology, Parasitology & Entomology

Phetsouvanh,R.Pnompenh Antimalarial drug resistance Chloroquine: CQ –1999: 46% treatment failure (33% RII/RIII) in VP – : 30-55% treatment failure in SVK, ATP, LN Sulfadoxine-pyrimethamine: SP –2001: 18-35% treatment failure in SVK, ATP –2002: 11% treatment failure in CPS (4% ETF, 7% LPTF) CQ+SP: –2001: 16-22% treatment failure in ATP –2002: 8% treatment failure in SVK Mefloquine: MQ –2001: 100% ACPR in ATP (14 days follow up) Artesunate+mefloquine: – : 100% ACPR in SVK and LN (42 days follow up) Artemether+lumefantrine: –2002: 97% ACPR in SVK (42 days follow up) –2003: 93% ACPR in LN (42 days follow up) Artekin(Dihydroartemisinin+piperaquine) –2004: 93% ACPR in SVK (42 days follow up)

Phetsouvanh,R.Pnompenh

4 Sentinel sites for drug monitoring in Lao PDR Proposed sentinel sites for in-vivo study in Laos Louangnamtha Louangprabang Houaphanh Savannakhet Champassack Attopeua

Past anti-malarial drug policy in Lao PDR Laos has adopted one treatment policy of malaria for different levels of health facilities systemtreatment policy Chloroquine or sulfadoxine/pyrimethamine for the treatment of uncomplicated malaria Quinine i.v. for complicated malaria and in case of treatment failure with CQ or SP. 1st line treatment (CQ) was available at village level

Enable VHWs in the correct treatment of uncomplicated malaria based upon clinical signs. Enable central-, regional-, provincial-,district hospitals to diagnose and treat complicated malaria correctly Regular monitoring of resistance to anti- malarial drug/ combinations at sentinel sites National policy included chemoprophylaxis for pregnant women and vulnerable groups, but implementation limited

Antimalarial drug resistance situation : –40-78% of failure to CQ (14/28/42 days) –18-36% of failure to SP (42 days) –8% of failure to CQ+SP (42 days) –92% of efficacy of Coartem ® (42 days) –100% of efficacy of A+M (42 days) 2003: –94% efficacy of Coartem ® (42 days) –100% efficacy of A+M (42 days)

Response to drug resistance Round table to discuss on the treatment policy (2003) Introduction of CQ plus SP as interim policy Change of policy to combination therapy: Coartem with the use of RDTs, esp at district and village level, free of charge to the patient Registration of Coartem blisters only use by NMCP Definition of 4 categories of weight and age Launch of procurement of ACT through WHO in December 2003 Production of guidelines on the use of RDT and ACT Production of IEC materials on the use of ACT TOT (incl on RDTs) in 3 pilot provinces (SRV, SK, ATP) in 2004, expanded to all provinces in 2005

Different options and alternatives Artesunate+mefloquine –First choice –Procurement issues: no product available meeting international GMP standards Alternative ACTs –Coartem ® was adopted as 1 st line treatment by Taskforce. Inform GFATM on change in policy, register Coartem, define weight and age dosages, produce new guidelines, new IEC materials, re- organize TOT on Coartem –Artekin ® : not currently WHO-recommended

What is the future in malaria treatment in Lao PDR?

New Malaria Treatment Policy, Lao PDR: 1st line: Artemether + Lumefantrine (CoArtem) – all levels of health services 2 nd line: Quinine + doxycycline Severe and complicated malaria: inj. Artesunate or quinine Small children: artesunate supp. Pregnant women: quinine or artesunate (from 2 nd trimester)

In 2002/2003 ACT was firstly introduced and closely followed up in 3 southern provinces of Laos: Attopeu, Sekong and Saravane where mortality and morbidity to malaria are high and evidence of DR is available. Implementation of ACT focuses on provincial and district hospitals including health centers. In pilot areas it is also implemented down to village level. In 2005, begin of countrywide implementation Implementation of the new policy

Efficacy monitoring of new policy continues in the 3 Lao sentinel sites, and regular review of results will be conducted As the combination is expensive (2.4US$ per adult dose) therefore it is required to perform a malaria test (microscopy or dipstick) and treatment is given only to P.f positive patient

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