Malaria Treatment & Prevention

Look at Malaysia

The mess in Burma is due to the chemical dependency of the malaria strategy of WHO and Burma, which is simply: drugs, drugs and biocides. Now the 2011 solution proposed by WHO is more of the same - drugs. What do you call it when you keep doing the same thing, and expect different results?

Look at Malaysia, just south of Burma, where malaria has been held in check for decades, and is currently at a barely detectable prevalence. They get a few thousand cases per year, and have been holding that steady low level for about 20 years. Why? Because the basis of their strategy is Environmental Management of mosquito habitats, and then a sparing use of drugs. Google Malaysia and malaria and look at their integrated vector management program. A few years ago I visited the island of Penang, just off Kuala Lumpur, and found their environmental measures still working since they were installed about 1938.

Of course you have to know something about the mosquitoes and their life styles. But it is the logical way to avoid the chemical dependency which always leads to drug and biocide resistance.

Bill

William Jobin, Sc.D.
Director of ...

Look at Malaysia

The mess in Burma is due to the chemical dependency of the malaria strategy of WHO and Burma, which is simply: drugs, drugs and biocides. Now the 2011 solution proposed by WHO is more of the same - drugs. What do you call it when you keep doing the same thing, and expect different results?

Look at Malaysia, just south of Burma, where malaria has been held in check for decades, and is currently at a barely detectable prevalence. They get a few thousand cases per year, and have been holding that steady low level for about 20 years. Why? Because the basis of their strategy is Environmental Management of mosquito habitats, and then a sparing use of drugs. Google Malaysia and malaria and look at their integrated vector management program. A few years ago I visited the island of Penang, just off Kuala Lumpur, and found their environmental measures still working since they were installed about 1938.

Of course you have to know something about the mosquitoes and their life styles. But it is the logical way to avoid the chemical dependency which always leads to drug and biocide resistance.

Bill

William Jobin, Sc.D.
Director of Blue Nile Associates
25558 Road N.6, Cortez, Colorado 81321

Both Bill and Paul are right. To control and eventually eradicate malaria,
we have to use all the weapons in the arsenal. The parasites have to be
killed through diagnosis and treatment, the vector mosquitoes have to be
killed through larvaeciding, Indoor Residual Spraying, and environmental
control, and the vectors and people have to be separated by universal use
of long lasting insecticide treated bednets.

Using only one of these strategies may slow malaria temporarily, and show
some results, but both the parasites and mosquitoes are very adaptable and
will develop resistance, especially to chemicals.

Recently we have had a wonderful coincidence of:

Affordable tools that work: Nets, Artemisinin and pyrithroids
Political will: which sets priorities and funding
External funding from Global Fund, PMI, Gates and others

Together these factors offer the world an opportunity to control and
possibly eliminate malaria forever.

However, we see that the parasites are developing resistance to
Artemisinin, as they have to all other drugs, the mosquitoes are developing
resistance to insecticides, as they have before, and mosquitoes are even
changing behaviors, feeding earlier and later, and outside houses, making
nets less effective.

At the same time, as malaria programs are becoming more successful, with ...

Both Bill and Paul are right. To control and eventually eradicate malaria,
we have to use all the weapons in the arsenal. The parasites have to be
killed through diagnosis and treatment, the vector mosquitoes have to be
killed through larvaeciding, Indoor Residual Spraying, and environmental
control, and the vectors and people have to be separated by universal use
of long lasting insecticide treated bednets.

Using only one of these strategies may slow malaria temporarily, and show
some results, but both the parasites and mosquitoes are very adaptable and
will develop resistance, especially to chemicals.

Recently we have had a wonderful coincidence of:

Affordable tools that work: Nets, Artemisinin and pyrithroids
Political will: which sets priorities and funding
External funding from Global Fund, PMI, Gates and others

Together these factors offer the world an opportunity to control and
possibly eliminate malaria forever.

However, we see that the parasites are developing resistance to
Artemisinin, as they have to all other drugs, the mosquitoes are developing
resistance to insecticides, as they have before, and mosquitoes are even
changing behaviors, feeding earlier and later, and outside houses, making
nets less effective.

At the same time, as malaria programs are becoming more successful, with
fewer children dying, political interest, and funding, passes on to other
priorities.

There is still time for success, but we have to be even more serious and
attack malaria on all fronts with everyone working together.

Good hunting to all.

Charles

--
Charles Llewellyn
114 Marsh Street
Beaufort, NC 28516

US Cell 919 599-2147
Bogota Cell (321) 490-0736

Dear friends,
I agree with Charles. The  malaria control to be effective must use all means available. In my opinion the curricula of our schools and colleges should make considerable efforts on this aspect. If the people of tropical regions could sleep under mosquito net every day, put screens on doors and windows, not create mosquito breeding sites, avoid self-medication, but used preventive medical treatment to eliminate the parasite, it is sure that malaria will be eradicated and resistance problems will have their importance in agriculture where pesticides continue to be widely used.
Best regards

Gil Germain PADONOU

yes i fully agree

anil

very well said
it has to be multi pronged attacak with involvement of communiy

Rwanda and Malaria have been together for several years .Malaria was coming as the 1st killer in adults and children
Nowdays due to environment tough management and mosquitos nets wide distribution the disease is not even in 5 most killers in the country.In our District Hospital which used to be with hundred of patients with Malaria ;u can spend 6 months without a single case of malaria.
I agree with Anil Varshney.First deal with prevention in the community


KABERA Rene,MD
Family Medicine
Rwanda

Dear All,
Despite the gains that have made in the fight against malaria, this killer disease is still firmly entrenched in our society in Africa.I think one way we can fight against this disease is by governments in to provide the much needed social infrastructure like good roads, housing, electricity. there was malaria in China 20 or so years ago but now one hardly hear about it. this is all due to how the country has developed.

Bill and Rene: It is heartening to learn about the successful control of malaria in Malayasia and Rwanda. I feel success stories ought to be widely studied and publicized for other countries and projects to learn from. Do you think you might have some statistics to share (before-after figures of malaria indicators would be great) from these two countries? You might also like to think of forums, listserves, discussion groups here in GHDOnline as well as outside where these facts and figures could be posted for wider dissemination. I am connected with a few of such networks and would be glad to pass on to you their links if you might like to share specific data from Malayasia and Rwanda.

To Paul Robinson


You may read these articles from PubMed and other independant websites

 
1. Reduced paediatric hospitalizations for malaria and febrile illness patterns following implementation of community-based malaria control programme in rural Rwanda.     http://www.ncbi.nlm.nih.gov/pubmed/18752677

2.Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment.    http://www.ncbi.nlm.nih.gov/pubmed/19144183
3.Progress in Rwanda's Fight Against Malaria  http://dr-agnes.blogspot.com/2012/02/progress-in-rwandas-fight-against.html


4.The Rwanda Health Survey 2010 is available on Internet via the website of National Institute of Statistics of Rwanda http://statistics.gov.rw/



Best regards


________________________________
KABERA René,MD
Family and Community Medicine
Rwanda

Hi Paul,

I mistakenly sent the data on Malaysia in an attachment, which the page does not support.

I have not worked in Malaysis but visited there several years ago and learned of their remarkable, and durable success.

So here is a summary of the total number of cases reported in the entire country by the MOH, since 1980.
They have data from earlier decades also, and their malaria control effort started about 1938.

For the complete graph and story, google “Malaysia malaria”

There is a also a WHO VBC publication on Malaysia by Jit Singh, but it is out of print.

1980 44,226
1990 54,831
2000 12,780
2004 6,154
2005 5,569
2006 5,546
2007 7,390

There are two lessons here.

ONE Malaysia, like several other tropical countries with falciparum malaria and efficient vectors, has suppressed transmission for about 70 years, using a wide combination of methods, but starting with environmental management.

TWO Suppression is possible, but there is no basis to think eradication is possible. But a continued broad-based program makes it possible to suppress malaria to acceptable and low prevalences.

Bill


William Jobin, Sc.D.
Director of Blue Nile Associates
25558 ...

Thanks for this discussion on artemisinin resistance. Although some still argue that there is no true artemisinin resistance, calling it increased artemisinin tolerance instead, there are several reasons why the seriousness of the observations in southeast Asia cannot be overstressed.
Firstly, without a current field deployable gold standard for unequivocally determining artemisinin resistance, the problem may spread insidiously to the rest of the world without being noticed. Secondly, for the patient, treatment failure leads to the same fate, whether it is ascribed to true resistance, increasing tolerance or malabsorption. Thus, tracking treatment failure per se and how it is changing over time should be encouraged in all endemic regions. The concern here is to avert a repeat of the global public health toll that occurred when the erstwhile most effective, safe and affordable antimalarial drug chloroquine, was rendered useless by resistance. Surely, we are still far from that, yet one can never be too cautious in making sure this does not happen again. Research to identify a molecular marker(s) for resistance is urgently needed in the meantime, so are public health strategies to maintain efficacy of artemisinin combination therapy. Lastly, while it is encouraging that emerging artemisinin resistance has ...

Thanks for this discussion on artemisinin resistance. Although some still argue that there is no true artemisinin resistance, calling it increased artemisinin tolerance instead, there are several reasons why the seriousness of the observations in southeast Asia cannot be overstressed.
Firstly, without a current field deployable gold standard for unequivocally determining artemisinin resistance, the problem may spread insidiously to the rest of the world without being noticed. Secondly, for the patient, treatment failure leads to the same fate, whether it is ascribed to true resistance, increasing tolerance or malabsorption. Thus, tracking treatment failure per se and how it is changing over time should be encouraged in all endemic regions. The concern here is to avert a repeat of the global public health toll that occurred when the erstwhile most effective, safe and affordable antimalarial drug chloroquine, was rendered useless by resistance. Surely, we are still far from that, yet one can never be too cautious in making sure this does not happen again. Research to identify a molecular marker(s) for resistance is urgently needed in the meantime, so are public health strategies to maintain efficacy of artemisinin combination therapy. Lastly, while it is encouraging that emerging artemisinin resistance has been detected early, and efforts were mounted to try and curb its spread, it is concerning that this seems to have occurred almost soon after wider deployment of ACTs to the rest of the endemic world. ACTs are currently a major reason why malarial burden is down in many parts of the world today and as rightly noted, all gains could be easily reversed, should resistance spread without effective alternative therapy. What is more concerning again is that the parasite appears to be eluding efforts to contain and eliminate the resistance in the original focus in western Cambodia.
The consensus regarding attacking malaria with all methods available is important. Field data from at least two areas of Africa[1, 2](see: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Cit...; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Cit... with links] have shown that implementing vector control led to reduction of the prevalence of malaria parasite resistance to chloroquine as well as sulfadoxine/pyrimethamine. As shown in one of these studies[1], when indoor residual spraying stopped, chloroquine resistance increased back. Recent data indeed suggest that mosquitoes may be playing a role in influencing levels of drug resistant malaria parasites that has not been previously noticed[3] (see: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Cit...). But we have far more to learn about all the parasite and vector-related factors so as to formulate rational public health strategies for drug resistance containment in integrated control and elimination programmes. At this time funding is even more critical to sustain, if the considerable progress attained so far is to prevail and for any chances to eventually eliminate the malaria scourge.

1. Mharakurwa S, Mutambu SL, Mudyiradima R, Chimbadzwa T, Chandiwana SK, Day KP: Association of house spraying with suppressed levels of drug resistance in Zimbabwe. Malar J 2004, 3:35.
2. Alifrangis M, Lemnge MM, Ronn AM, Segeja MD, Magesa SM, Khalil IF, Bygbjerg IC: Increasing prevalence of wildtypes in the dihydrofolate reductase gene of Plasmodium falciparum in an area with high levels of sulfadoxine/pyrimethamine resistance after introduction of treated bed nets. Am J Trop Med Hyg 2003, 69(3):238-243.
3. Mharakurwa S, Kumwenda T, Mkulama MA, Musapa M, Chishimba S, Shiff CJ, Sullivan DJ, Thuma PE, Liu K, Agre P: Malaria antifolate resistance with contrasting Plasmodium falciparum dihydrofolate reductase (DHFR) polymorphisms in humans and Anopheles mosquitoes. Proc Natl Acad Sci U S A 2011, 108(46):18796-18801.

Sungano presents some very interesting data on how anopheline populations may be modulating resistance to chemotherapeutics in human populations. A field deployable assay for genetic and other potential resistance mechanisms that is robust in adverse environments is a must and should be made a priority. Without reliable data on the presence/absence and/or frequency of resistance to ACT, sulfa and other drugs & drug combos the treatment community is left to use these valuable resources"in the dark" when such decisions such be driven by timely and solid surveillance data. Working groups that are currently meeting or plan to meet in the future to develop protocols for the administration of these drugs would be strongly served by advocating now for improved diagnostic capability to detect resistance to artemisinin-based and other therapies.

Question for Sungano- could you in a few short sentences state a hypothesis for how vector control measures are modulating resistance to parasites in humans? This a a fascinating story and one I think the community would be well served to understand better. I know I would. Thank you too for sharing the literature cited with the community.

BTW- I couldn't agree with you more about your assessment ...

Sungano presents some very interesting data on how anopheline populations may be modulating resistance to chemotherapeutics in human populations. A field deployable assay for genetic and other potential resistance mechanisms that is robust in adverse environments is a must and should be made a priority. Without reliable data on the presence/absence and/or frequency of resistance to ACT, sulfa and other drugs & drug combos the treatment community is left to use these valuable resources"in the dark" when such decisions such be driven by timely and solid surveillance data. Working groups that are currently meeting or plan to meet in the future to develop protocols for the administration of these drugs would be strongly served by advocating now for improved diagnostic capability to detect resistance to artemisinin-based and other therapies.

Question for Sungano- could you in a few short sentences state a hypothesis for how vector control measures are modulating resistance to parasites in humans? This a a fascinating story and one I think the community would be well served to understand better. I know I would. Thank you too for sharing the literature cited with the community.

BTW- I couldn't agree with you more about your assessment of how funding should be based on "rational {data-driven] public health strategies". We, the malaria community have no time to waste on ineffectual strategies that will simply end up leading us to repeat many of the same mistakes made during previous efforts to eliminate malaria transmission. Many thanks, -Mike

Thanks, Mike.
The strange reality is that this "thinking" parasite does seem to stay ahead of us, even in this day and age. Field observations on the link between vector control and parasite drug resistance in humans still remain pretty much observations. Hypotheses for the underlying mechanistic basis could be as many as there are proponents, and potentially controversial, as usual.
However, having recently seen that mosquitoes appear to exert selection on Plasmodium falciparum drug resistance alleles, it is only beginning to make sense how vector control can also impact on parasite drug resistance. Sporogonic selection in the mosquito could be due to fitness differences between mutated and wild-type parasite alleles. Gametocyte formation differences may be involved as well, or neither of these hypotheses. At present, anybody's guess is good until controlled studies specifically look at this phenomenon, by vector species.

What seems clear at this time is that we may have to also take the vector (and its selection) into consideration if we want to effectively gain an upper hand on drug resistance.