The World Health Organization (WHO) is releasing new guidelines for the treatment of malaria, and the first ever guidance on procuring safe and efficacious anti-malarial medicines.
In recent years a new type of treatment called artemisinin-based combination therapy (ACTs) has transformed the treatment of malaria, but if not used properly the medicine could become ineffective.
Guidelines emphasize testing
The Guidelines for the Treatment of Malaria (second edition) provide evidence-based and current recommendations for countries on malaria diagnosis and treatment. The main changes from the first edition of the guidelines (published in 2006) are the emphasis on testing before treating and the addition of a new ACT to the list of recommended treatments.
"The world now has the means to rapidly diagnose malaria and treat it effectively" said Dr Robert Newman, Director of the WHO Global Malaria Programme (GMP). "WHO now recommends diagnostic testing in all cases of suspected malaria. Treatment based on clinical symptoms alone should be reserved for settings where diagnostic tests are not available," he added.
In 2008, just 22% of suspected malaria cases were tested in 18 of 35 African countries reporting. Until now, most clinics had to rely on microscopy, but the recent development of quality-assured Rapid Diagnostic Tests (RDTs) using a dip stick and a drop of blood means a policy change is possible. The tests can reliably demonstrate the presence or absence of malaria parasites in the blood and can be performed at all levels of the health system, including community settings.
Universal diagnostic testing
The move towards universal diagnostic testing of malaria is a critical step forward in the fight against malaria as it will allow for the targeted use of ACTs for those who actually have malaria. The aim is to reduce the emergence and spread of drug resistance and to help identify patients who have fever, but do not have malaria, so that alternative diagnoses can be made and appropriate treatment provided. Therefore, better management of malaria has a positive impact on management of other childhood illness and overall child survival.
WHO is supporting malaria endemic countries to improve the quality of their diagnostic services using both microscopy and RDTs, and urging the manufacturers of RDTs to continue improving the accuracy and quality of these critically important diagnostic tests.
WHO estimates that 80 countries have adopted ACTs for first-line treatment of uncomplicated P. falciparum malaria. In the guidelines, WHO emphasizes the importance of treating this deadliest form of the disease with artemisinin-based combination therapies. WHO has now added a fifth ACT - dihydroartemisinin plus piperaquine - to the previous list of recommended medicines.
Preventing drug resistance
WHO recommends oral artemisinin-based monotherapy should be removed from the market because their use will hasten the development of parasite resistance. Countries need to ensure that patients are diagnosed properly and take the full dose of ACTs to prevent the development of drug resistance.
Procurement quality
The first ever guidelines on Good procurement practices for artemisinin-based antimalarial medicines are based on the newest stringent internationally agreed production and procurement quality standards. This manual aims to improve the capacities of national and international procurement officers in the understanding of key quality elements and required documentation. The content is presented as a practical and concise 16-step practical checklist to guide the selection and procurement of safe and effective medicines meeting international quality standards.
"Pharmaceutical markets in malaria endemic countries are often unregulated and national authorities need practical help to assess the quality of malaria medicines before they buy them" says Dr Andrea Bosman, Coordinator of the Medicines and Diagnostics Unit at GMP. "Procurement channels are highly fragmented and so there are too many antimalarials of varying quality on the market."
Poor-quality medicines affect the health and lives of patients, damage the credibility of health services and, by generating sub-therapeutic drug levels in malaria patients, help develop resistance to this important life-saving class of pharmaceuticals.
"These guidelines will help countries select and procure effective medicines of good quality and save lives by improving the way patients are diagnosed and treated," says Dr George Ki-Zerbo, Malaria Programme Manager at the WHO Regional Office for Africa in Brazzaville.
Half of the world's population is at risk from malaria. Each year almost 250 million cases occur, causing 860 000 deaths. Approximately 85% of these deaths are among children, and most occur in Africa.
A promising new strategy for malaria drug development