Since the start of the epidemic, MSF has been asking to use a combination treatment because of its safety and efficacy. It would have enabled MSF doctors to treat patients effectively and possibly halt the spread of the epidemic.
In Burundi, the number of cases of malaria has increased alarmingly in the last few years: two million cases were reported in 1999, compared to 200,000 ten years earlier.
In October 2000, a malaria epidemic worse than any seen before swept through six of the country's 16 provinces. It lasted six months and more than three million cases were reported countrywide (for 6.5 million inhabitants).
For the first time, regions of low risk (high plateaus from 1,400-1,700 metres' altitude) were also affected. In these regions, people have poor immune protection, which helped the spread of the epidemic and caused a high mortality rate.
Several factors were involved in the emergence and lasting nature of this epidemic: growth of the mosquito population caused by farming in swamp areas, abandonment of the vector control programme due to the 1993 war, and the high levels of resistance to the drugs recommended by the national protocol (chloroquine and Fansidar®).
High levels of resistance to classical antimalarials
In early 2001, MSF, in collaboration with the MOH, carried out resistance studies in Burundi according to the WHO protocol (1996). The results of these studies showed very high levels of resistance to classical antimalarials chloroquine and Fansidar®.
54.2% resistance to SP ; 42% resistance to chloroquine SP
91.3% resistance to chloroquine and 66.7% resistance to SP
63.8% resistance to chloroquine and 32.7% resistance to SP
As a reminder, WHO considers that 25% resistance is the rate at which it becomes imperative to change the treatment protocol.
Unsuitable national treatment protocol
In 2000, Burundi's national protocol recommends the use of chloroquine for first-line malaria treatment and Fansidar® as second-line.
In 2001, in response to the results of resistance studies carried out in six provinces, the government decides to adopt a "transition protocol" recommending the use of Fansidar® as first-line treatment and quinine as second-line. The use of Coartem (a fixed dose combination of artemether and lumefantrine) is reserved for epidemics only. This protocol therefore advocates a first-line treatment which has been proven ineffective, and a restrictive second-line treatment (5-7 day treatment) which may reduce compliance and increase the risk of resistance.
Since the start of the epidemic, MSF has been asking to use an artemisinin derivative in combination with an effective classical antimalarial. This combination, recommended by most experts because of its safety and efficacy, would have enabled MSF doctors to treat patients effectively and possibly halt the spread of the epidemic.
At the end of 2001, the Burundi government started effectiveness studies for artemisinin-containing combinations: artesunate amodiaquine, and Coartem. While waiting for the results of these studies, which will not be available for several months, patients continue to be treated with ineffective drugs. Artemisinin derivatives are available in most private pharmacies in Burundi, but they are only prescribed to patients who can afford to pay for the treatment themselves.
MSF and malaria
MSF runs programmes in several provinces of Burundi (Kayanza, Ngozi, Karuzi and Cankuso), and gives support to health centres and public hospitals. MSF teams played a very active role diagnosing and treating malaria patients during the last epidemic (end of 2000, beginning of 2001).
Today, MSF is fighting for the right to treat patients with effective medicines. MSF anxiously awaits the results of the resistance study and consequent government decisions regarding change of national protocol. As it stands, the national protocol recommends giving patients drugs that simply don't work - MSF considers this unacceptable.