Urgent strategies needed to fight artemisinin resistance in East Africa

Artemisinin-based combination therapies (ACTs) have become the cornerstone of malaria treatment and control. However, the recent emergence and spread of artemisinin-resistance (ART-R) in malaria-causing Plasmodium falciparum parasites in eastern Africa has compromised the efficacy of these crucial treatments.

In a Policy Forum, Mehul Dhorda and colleagues argue that urgent action is needed to prevent a surge in malaria-related sickness and death in the region. "Success in containing ART-R in the Greater Mekong Subregion in Asia, where ART-R was first reported in 2008, suggests that a multipronged approach is needed in East Africa to reduce and interrupt malaria transmission permanently," write Dhorda et al. ACTs were first recommended by the World Health Organization as a first-line treatment for malaria in 2006, and their use has since significantly reduced the global burden of malaria. However, resistance to artemisinin spread quickly across Southeast Asia, posing a significant public health emergency. To combat this, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) supported the Regional Artemisinin-resistance Initiative (RAI), which worked in close coordination with national malaria control programs focusing on enhanced surveillance, rapid diagnosis, and mass drug administration in malaria hot spots.

These concerted efforts led to a significant decline in malaria throughout the region, despite the prevalence of ART-R. Recently, ART-R has increased across East Africa. Here, Dhorda et al. suggest that investment into programs like those used in Southeast Asia to battle ART-R is needed for this region to prevent a public health crisis. To counter ART-R in Africa, the authors recommend using triple ACTs (TACTs), combining an artemisinin derivative with two partner drugs, which have proven effective in Asia. Investments in enhanced community health worker networks, rapid diagnostic testing, and antimalarial treatments are crucial, and malaria vaccination and vector control measures, such as insecticide-treated bed nets and indoor residual spraying, could help reduce transmission. Moreover, regular monitoring of drug resistance is essential, and new strategies using recently approved novel malaria vaccines should be implemented to address this growing threat in Africa. "Funders, specifically the GFATM and the US government's President's Malaria Initiative, stepped up funding for malaria control and elimination programs to contain the spread of ART-R in Asia," write the authors. "A similarly visionary approach is now needed to protect the populations at risk in Africa."