Medicine and health policy

Effective malaria treatments, such as artemisinin-based combination therapy, should become more widely available, the report argued, and donor agencies should support implementation of artemisinin-based combination therapy, rather than "wasting their money on funding drugs that don't work".

WHO and UNICEF appealed for urgent increased action to combat malaria, after the publication of a joint report to mark Africa Malaria Day. The Africa Malaria Report 2003, released on April 25, stressed that the death toll from malaria is still "outrageously high", killing more 3000 children in Africa every day, and that effective antimalarial drugs and insecticide-treated bed nets are not widely available to those who need them.

"Millions of people continue to suffer and die unnecessarily with 90% of malaria deaths occurring in Africa alone", said Atoumata Nafo-Traoré, Executive Secretary of the Roll Back Malaria Partnership Secretariat, at the launch of the report in Nairobi, Kenya. "We now have the tools and the knowledge that are needed to slow the progress of malaria. But we have not yet managed to deploy them on a sufficient scale Africa-wide."

At a conference held simultaneously in London, UK, to mark the release of the report, Jane Crawley, an adviser to WHO's malaria department, noted that widespread use of insecticide-treated bed nets could greatly reduce malaria transmission. Coverage with nets, however, remains poor.

"Only 15% of children less than 5 years are sleeping under nets, and an even smaller proportion --less than 3%--are sleeping under nets that have been insecticide-treated."

During pregnancy, sleeping under insecticide-treated nets reduces the risk of giving birth to low birthweight babies and babies that are likely to become anaemic, both of which increase the risk of death. But, at less than 10%, use of bed nets among pregnant women is still low, Crawley said.

Resistance to antimalarial drugs is perhaps the greatest challenge in malaria treatment, the report noted. Resistance to the antimalarial drugs choloroquine and sulfadoxine-pyrimethamine is now so high in parts of Africa that both drugs are virtually useless.

In a report published on the eve of the WHO report, Médecins sans Frontières (MSF) said the continuing use of ineffective drugs despite high levels of resistance is leading to increasing treatment failures and death. Effective malaria treatments, such as artemisinin-based combination therapy, should become more widely available, the report argued, and donor agencies should support implementation of artemisinin-based combination therapy, rather than "wasting their money on funding drugs that don't work".

WHO currently recommends combination treatment with two antimalarial drugs that have different targets within the malaria parasite, one of which should be an artemisinin derivative.

Artemisinin drugs, which have been used for longer than 10 years in Asia, are rapidly acting, highly effective, and well tolerated. No resistance to artemisinins has been reported to date.

Several African countries have already changed their drug protocols--or are in the process of changing them--to include more effective treatments. For instance, KwaZulu province in South Africa has successfully changed to artemisinin-based combination therapy as first-line treatment, and Burundi, Zambia, and Zanzibar in Tanzania are preparing to implement the switch. However, lack of money and international help has forced some countries to switch to another monotherapy, or to less expensive non-artemisinin combinations.

"Since 2001, WHO experts have recommended replacing failing malaria medicines with more effective treatments, but donors have failed to encourage this change, choosing to save money rather than lives", said Bernard Pécoul, Director of MSF's Campaign for Access to Essential Medicines. "The G8 and African leaders' goal of halving malaria deaths by 2010 will remain a fantasy unless donors are willing to help pay for treatment that works."

But donors such as the UK Department for International Development (DFID) and the US Agency for International Development (USAID), are currently supporting a "go slow" approach, the MSF report said, mainly due to the higher cost of artemisinin-based combination therapy. Currently, chloroquine and sulfadoxine-pyrimethamine cost about US$0·15 per adult treatment dose, whereas artemisinin-based combination therapy costs at least US$1-2, although this is expected to go down to $0·50-0·80 by 2004-05 as orders for the drug increase.

"But what would you rather do", said Nick White (Mahidol University, Thailand, and Oxford University, UK), "waste money on old, cheap drugs that you know don't work, or fund a more expensive treatment that will save lives".

MSF estimates that, for all Africa, the cost of changing to artemisinin-based combination therapy is about $100-200 million per year.