1. Malaria treatment (Current WHO recommendations & guidelines)
Presentation by Dr Maryse Dugué RBM Partnership Secretariat, Malaria Medicines & Supplies Services
Copenhagen – 31 January 2006
7.3

2. Malaria distribution and reported case of resistance or treatment failure

3. First demonstration project in Thailand
Treatment efficacy at Thai-Burmese border
Thailand has been known for two decades as the country, where one antimalarial treatment after another has become ineffective following around 10 years of use. Thus, by the mid-1990s, the efficacy of mefloquine 25 mg/kg in western Thailand was as low as 75% (parasitological cure rate in 42 day tests). The combination of quinine and tetracycline (QT) has maintained its efficacy relatively well, but is considered far from satisfactory because of the long duration of the regimen (7 days), which leads to poor adherence. Following a number of clinical trials, it was decided to introduce a combination of artesunate 4mg/kg/day x 3 with mefloquine 25mg/kg in the most multi-drug resistant areas in the west of the country from This regimen has maintained a 42 day parasitological cure rate of around 95% since it was introduced. This is a truly remarkable achievement, and must be related to the artesunate, which is short-acting and to which no true resistance has been detected so far, somehow protecting the long-acting mefloquine, which has a long terminal half-life and is very vulnerable to the development of resistance.

4. Adoption of ACT as first-line treatment in 2000
Countries with falciparum malaria
Few countries deployed ACTs
in selected provinces/districts

5. ACT as first-line malaria treatment in 2006
Countries with falciparum malaria
Countries which adopted ACT as 1st-line treatment

6. 56 countries have adopted ACTs
Updated
15 Jan. 2006
Continent
Countries
Drug
Line
AFRICA
Burundi, Cameroon, Côte d'Ivoire, DRC, Eq.Guinea, Gabon, Ghana, Guinea, Liberia, Madagascar, Senegal, ST&P, Sierra Leone, Sudan (S), Zanzibar
AS + AQ
1st
Angola, Benin, Burkina Faso, Comoros, Ethiopia, Gambia, Guinea Bissau, Kenya Mali, Namibia, Niger, Nigeria, Rwanda, Uganda, S. Africa, Tanzania, Togo, Zambia AL
Côte d'Ivoire, Gabon, Mozambique, Sudan (N), ST&P, Zanzibar
2nd
Mozambique, Sudan (N), South Africa (Mpumalanga)
AS + SP
ASIA
Cambodia, Thailand
AS + MQ
Bangladesh, Bhutan, Laos, Myanmar
Indonesia
Afghanistan, India (5 Provinces), Iran, Tajikistan, Yemen
Viet Nam DP
Papua New Guinea
Philippines, Iran
SOUTH
AMERICA
Ecuador, Peru
Bolivia, Peru, Venezuela
Brazil, Guyana, Suriname
AQ=amodiaquine; AL=artemether/lumefantrine; AS=artesunate; DP=dihydroartemisinin/piperaquine; MQ=mefloquine; SP=sulfadoxine/pyrimethamine

7. 26 countries are deploying ACTs
Updated
15 Jan. 2006
Continent
Countries
Drug
Line
AFRICA
Burundi, Cameroon, Côte d'Ivoire, DRC, Eq.Guinea, Gabon, Ghana, Guinea, Liberia, Madagascar, Senegal, ST&P, Sierra Leone, Sudan (S), Zanzibar
AS + AQ
1st
Angola, Benin, Burkina Faso, Comoros, Ethiopia, Gambia, Guinea Bissau, Kenya Mali, Namibia, Niger, Nigeria, Rwanda, Uganda, S. Africa, Tanzania, Togo, Zambia AL
Côte d'Ivoire, Gabon, Mozambique, Sudan (N), ST&P, Zanzibar
2nd
Mozambique, Sudan (N), South Africa (Mpumalanga)
AS + SP
ASIA
Cambodia, Thailand
AS + MQ
Bangladesh, Bhutan, Laos, Myanmar
Indonesia
Afghanistan, India (5 Provinces), Iran, Tajikistan, Yemen
Viet Nam DP
Papua New Guinea
Philippines, Iran
SOUTH
AMERICA
Ecuador, Peru
Bolivia, Peru, Venezuela
Brazil, Guyana, Suriname
29% deploying
60% deploying
71% deploying
AQ=amodiaquine; AL=artemether/lumefantrine; AS=artesunate; DP=dihydroartemisinin/piperaquine; MQ=mefloquine; SP=sulfadoxine/pyrimethamine

8. Malaria diagnosis
Parasitological confirmation (microscopy or RDT) before treatment
Exceptions:
children under 5 years of age, from areas of high transmission where treatment is based on clinical diagnosis
suspected severe malaria where parasitological confirmation is not immediately possible

9. Changing antimalarial treatment policy
Treatment failure of >10% (as assessed through monitoring of therapeutic efficacy at 28 days)
New treatment – an average cure rate of > 95% as assessed in clinical trials

10. Treatment of uncomplicated falciparum malaria
Artemisinin-based combination therapies (ACT) are the treatments recommended for all cases of uncomplicated falciparum malaria including:
in infants,
in people living with HIV/AIDS
for home-based management of malaria
pregnant women in the 2nd and 3rd trimesters
Exception:
1st trimester of pregnancy

11. Treatment of uncomplicated falciparum malaria
The following ACTs are presently recommended:
artemether-lumefantrine
artesunate + amodiaquine
artesunate + mefloquine
artesunate + sulfadoxine-pyrimethamine
Efficacy of ACTs depend on the efficacy of the partner medicine
The artemisinin derivatives (oral formulations) and partner medicines of ACTs are not recommended as monotherapy

12. Treatment of uncomplicated falciparum malaria
Second-line treatment:
alternative ACT
quinine + tetracycline or doxycycline or clindamycin

13. Treatment of severe falciparum malaria
Any of the following antimalarial medicines are recommended
Artesunate i.v. or i.m
artemether i.m.
quinine (i.v. infusion or i.m. injection).
Full course of ACT or quinine + clindamycin or doxycycline when patient can tolerate oral treatment

14. How to contact us… Malaria Medicines & Supply Services (MMSS)
Roll Back Malaria Partnership Secretariat
Website:
Dr Maryse Dugue
Manager
Tel: +41 (0)