EDITORIAL
Malaria control in Malawi A large problem Like the rest of Sub-SaharanAfrica, malaria in Malawi continues to be one of the most important public health problems that our population faces; accounting for between 30 to 40Vaof hospital visits and 20 to 30Voof hospital deaths,especially among children under the age of five years. Pregnant women are also susceptible to the devastating effects of malaria infection, although the major impact of malaria infection in pregnancy is not on the woman herself but on her unbom child, whose growth may be impaired as a consequenceof the accumulation of parasites in the placenta. About 207o of Malawian babies are born with low birth weight (LBW), the most important predictor of neonatal and infant mortality, and malaria is the most impofiant preventable causeof LBW.
alternative antimalarial drugs which included sulphadoxine pyrimethamine (SP), amodiaquine,mefloquine and halofantrine. Six sentinel sites were set up, three along the lakeshoreand three inland for in-vivo drug efficacy studies. Amodiaquine was quickly deletedfrom the national formulary becauseof common problems with severe abdominal pains. The others were abandoned on the basis of unaffordable cost.
Drug resistance:the change to SP After over eight years of systematic efficacy studies involving CQ and SP, it was clear that by 1990 over 80Vo of the Plasmodium falciparum infections were exhibiting the most severe form of resistance to CQ, i.e RII and RIII. In addition there were less than 5Vo of the parasites showing resistanceto SP.These were systematicin-vivo studies on children under the age of 5 years. In parallel to the increasing CQ resistanceof the parasitesto CQ, there was also increasing resistanceamong the consumers - i.e mothers of sick children - to accept CQ treaf ment for their children. Consequently a national consensus Many schemes It has been argued,correctly, that no African country is success- meeting of stakeholdersdecided in 1991 to change from CQ to fully controlling malaria, and that this is one reason why we SP as first line treatment for uncomplicated malaria infection. 'launch'of the new treatmentpolicy was in 1993.The have had so many "new" initiatives from WHO and other inter- The actual period lag was neccessitated by the logistics of procuring national bodies to try to tackle the immense problems causedby enough SP to trickle down to all health centres (we wanted to malaria. Beginning with The Accelerated Implerientation of 'new'drug avoid the scenario where a is announcedand patients Malaria Control in the early 90s, we moved through the African 'movement', find that it's not available at the health centre), training health Malaria Initiative to the Roll Back Malaria (RBM) workers and also to develop I.E.C materials for community spearheadedby WHO, World Bank, UNICEF and UNDP. There 'strong information. has been evidencein the African region of political will' to control malaria in the form of The Harare Declaration and recently TheAbuja Declaration signedby our headsof State and Other measures Government. Malawi is a signatory to both these landmark dec- Even though the most notable change was the switch from CQ to SP; there were other changes made for the management of larations. malaria at the samemeeting. A20mgkgloading dose of quinine was addedto the managementof severemalaria , parenteralquiA resourceful enemy In spite of all these efforts the malaria problem continues to nine was introduced for intramuscular use at the health centre escalate alarmingly. One of the major contributing factors to level (after recognising that patients with severemalaria need to this escalation has been the increasing problem of parasite be startedon effective antimalarial treatment at the health centre resistanceto the commonly used first line antimalarial drugs. prior to referral, a process which can sometimes take hours to When malaria control programme managers from the sub- achieve) and finally two dosesof SP were introduced to replace Saharan region meet to share country experiences,they show weekly CQ for prophylaxis during pregnancy. This is now a graphic slides or transparenciesportraying in each country ever practice that has now been adopted and promoted by WHO as increasing levels of mortality and morbidity from malaria. Such Intermittent Presumptive Treatment (IPT) in pregnancy. experiencesmade us realise that our Control Programmes had turned into Malaria Mortality and Morbidity Monitoring Programmes, since in spite of the alarming data that were being gatheredour main tool for control remained the same. Diagnosis and treatment WHO recommendsthree main arms to a malaria control strategy: case managementpersonal protection (including the use of insecticide treated materials, ITM's ) and selective vector control; the main focus of our control efforts has been the first of these, namely early and appropriate case management Case management by necessity requires the use of drugs. For this strategyto have an impact there is need for an effective and efficacious drug. Malawi's Control Programme Recognising this simple fact and seeing the escalating malaria problem, the Malawi Ministry of Health setup a Malaria Control Programme in 1984. Its mandatewas to monitor the efficacy of the currently recommendedfirst line treatment for uncomplicated malaria at the time, chloroquine (CQ). and also to study other 2
Research informing policy It is important to note that changesmade to malaria management were based on locally generated data, with good collaboration between malaria researchers,malaria control programme and policy makers within the Ministry of Health. An excellent example of applying research findings to prograrnme policy and implementation. This collaboration continues to be implemented mainly through annual malaia researchdissemination meetings. Since the change in 1993, SP efficacy has continued to be monitored at sentinel sites throush in-vivo testins as before. SP has done well As is to be expectedwith the continued use of any antimicrobial (whether antibacterial, antiviral or antiparasitic), the more it is used the more likely it is that resistance will develop. This is what we are seeing with SP. The parasite resistance has increasedfrom less than 5Voin the early 90's to as high as 207o at some sites in 2001. The rate of increase of SP resistancehas not been as rapid as had been predicted in certain circles. SP is still effective in more than 807oof the malaria casestreated and therefore remainsthe first choice for treatment of uncomplicated Malawi Medical Jomal
EDITORIAL malaria in Malawi after about 10 years of widespreaduse we should not forget that multitude of children's lives that have been saved by the use of a more effective drug than CQ during this period. Being prepared Realising however that at some stage in future SP will have to give way to another more effective drug or combination of drugs, the Programme is encouraging research in this area of alternatives to SP; one of the most advancedprojects has been the study of Chloryroguanil-Dapsone or LAPDAP at Ndirande Health Centre (Blantyre). We are also looking at the possibility of studying compounds containing the artemisinin derivatives since WHO now recommends moving towards what is referred to as Combination Therapy or CT. This approachdraws on the experienceof treatment of malignancies,TB and HIV infection - it is designed to reduce the chancesof a parasite developing resistance by using two or more drugs that have independent modes of action and different biochemical targetsin the parasite. Using this definition, SP does not qualify as CT. The National Malaria Control Programme is also concemed about optimising the uptake of IPT-SP becausethere is now evidence that nationally only about 3'77oof pregnant women are taking the full two dosesof SP in spite of high antenatalclinic attendanceand also good knowledge about both the IPT regime and the safety of SP
This issue of Malawi Medical Journal was supported by a generousdonation from the Centers for Disease Control (CDC), Atlanta, Georgia,USA, and by the Blantyre Integrated Malaria Initiative (BIMI), Blantyre, Malawi.
in pregnancy. Another problem is the mounting evidence that women who are HIV infected require more than the two doses of SP to achieve the same benefit of reduction of placental malaria and consequentreduction in LBW as those women who are not HIV infected. Studies will soon be underway to address this issue. Working together In conclusion, it is important to remember that Malawi has contributed significantly to the international malaria control efforl by sharing her experience in managing a national antimalarial drug policy change. Malawi has also contributed a large body of knowledge in managing malaria in pregnancy and in the management of severe malaria - IPT-SP and the Blantyre Coma Score are visible such contributions. The articles in this edition of MMJ are further testimony of the excellent work done in this field. The history of malaria control in Malawi has been one of policy driven by locally generatedrelevant scientific data and this has been made possible by the good working relations between researchers and programme implementers. We will continue to nurture this relationship, which is ultimately beneficial to our people. Peter N Kazembe Chairman, M alaria Control Committee
Calls for papers
SpecialHIV - AIDS issueof MMJ GuestEditor Dr John Chisi The next issueof MMJ will focus on HIV - AIDS. You are warmly invited to contribute material of anv of the followine kinds: o o a o o o a a
Personalview Casereport Descriptionof a programme Scientific article (researchor audit) Letter to editor Conferencereport Poem other
Submissionsshould reachthe Guest Editor by 30 July 02. Pleasesubmit either as e-mail attachmentto [email protected] Or as paper copy with accompanying diskette,addressedto Dr John Chisi, College of Medicine,PlBag 360, Blantyre
\l:lagi
Medical Joumal
Malaria control in Malawi A large problem Like the rest of Sub-SaharanAfrica, malaria in Malawi continues to be one of the most important public health problems that our population faces; accounting for between 30 to 40Vaof hospital visits and 20 to 30Voof hospital deaths,especially among children under the age of five years. Pregnant women are also susceptible to the devastating effects of malaria infection, although the major impact of malaria infection in pregnancy is not on the woman herself but on her unbom child, whose growth may be impaired as a consequenceof the accumulation of parasites in the placenta. About 207o of Malawian babies are born with low birth weight (LBW), the most important predictor of neonatal and infant mortality, and malaria is the most impofiant preventable causeof LBW.
alternative antimalarial drugs which included sulphadoxine pyrimethamine (SP), amodiaquine,mefloquine and halofantrine. Six sentinel sites were set up, three along the lakeshoreand three inland for in-vivo drug efficacy studies. Amodiaquine was quickly deletedfrom the national formulary becauseof common problems with severe abdominal pains. The others were abandoned on the basis of unaffordable cost.
Drug resistance:the change to SP After over eight years of systematic efficacy studies involving CQ and SP, it was clear that by 1990 over 80Vo of the Plasmodium falciparum infections were exhibiting the most severe form of resistance to CQ, i.e RII and RIII. In addition there were less than 5Vo of the parasites showing resistanceto SP.These were systematicin-vivo studies on children under the age of 5 years. In parallel to the increasing CQ resistanceof the parasitesto CQ, there was also increasing resistanceamong the consumers - i.e mothers of sick children - to accept CQ treaf ment for their children. Consequently a national consensus Many schemes It has been argued,correctly, that no African country is success- meeting of stakeholdersdecided in 1991 to change from CQ to fully controlling malaria, and that this is one reason why we SP as first line treatment for uncomplicated malaria infection. 'launch'of the new treatmentpolicy was in 1993.The have had so many "new" initiatives from WHO and other inter- The actual period lag was neccessitated by the logistics of procuring national bodies to try to tackle the immense problems causedby enough SP to trickle down to all health centres (we wanted to malaria. Beginning with The Accelerated Implerientation of 'new'drug avoid the scenario where a is announcedand patients Malaria Control in the early 90s, we moved through the African 'movement', find that it's not available at the health centre), training health Malaria Initiative to the Roll Back Malaria (RBM) workers and also to develop I.E.C materials for community spearheadedby WHO, World Bank, UNICEF and UNDP. There 'strong information. has been evidencein the African region of political will' to control malaria in the form of The Harare Declaration and recently TheAbuja Declaration signedby our headsof State and Other measures Government. Malawi is a signatory to both these landmark dec- Even though the most notable change was the switch from CQ to SP; there were other changes made for the management of larations. malaria at the samemeeting. A20mgkgloading dose of quinine was addedto the managementof severemalaria , parenteralquiA resourceful enemy In spite of all these efforts the malaria problem continues to nine was introduced for intramuscular use at the health centre escalate alarmingly. One of the major contributing factors to level (after recognising that patients with severemalaria need to this escalation has been the increasing problem of parasite be startedon effective antimalarial treatment at the health centre resistanceto the commonly used first line antimalarial drugs. prior to referral, a process which can sometimes take hours to When malaria control programme managers from the sub- achieve) and finally two dosesof SP were introduced to replace Saharan region meet to share country experiences,they show weekly CQ for prophylaxis during pregnancy. This is now a graphic slides or transparenciesportraying in each country ever practice that has now been adopted and promoted by WHO as increasing levels of mortality and morbidity from malaria. Such Intermittent Presumptive Treatment (IPT) in pregnancy. experiencesmade us realise that our Control Programmes had turned into Malaria Mortality and Morbidity Monitoring Programmes, since in spite of the alarming data that were being gatheredour main tool for control remained the same. Diagnosis and treatment WHO recommendsthree main arms to a malaria control strategy: case managementpersonal protection (including the use of insecticide treated materials, ITM's ) and selective vector control; the main focus of our control efforts has been the first of these, namely early and appropriate case management Case management by necessity requires the use of drugs. For this strategyto have an impact there is need for an effective and efficacious drug. Malawi's Control Programme Recognising this simple fact and seeing the escalating malaria problem, the Malawi Ministry of Health setup a Malaria Control Programme in 1984. Its mandatewas to monitor the efficacy of the currently recommendedfirst line treatment for uncomplicated malaria at the time, chloroquine (CQ). and also to study other 2
Research informing policy It is important to note that changesmade to malaria management were based on locally generated data, with good collaboration between malaria researchers,malaria control programme and policy makers within the Ministry of Health. An excellent example of applying research findings to prograrnme policy and implementation. This collaboration continues to be implemented mainly through annual malaia researchdissemination meetings. Since the change in 1993, SP efficacy has continued to be monitored at sentinel sites throush in-vivo testins as before. SP has done well As is to be expectedwith the continued use of any antimicrobial (whether antibacterial, antiviral or antiparasitic), the more it is used the more likely it is that resistance will develop. This is what we are seeing with SP. The parasite resistance has increasedfrom less than 5Voin the early 90's to as high as 207o at some sites in 2001. The rate of increase of SP resistancehas not been as rapid as had been predicted in certain circles. SP is still effective in more than 807oof the malaria casestreated and therefore remainsthe first choice for treatment of uncomplicated Malawi Medical Jomal
EDITORIAL malaria in Malawi after about 10 years of widespreaduse we should not forget that multitude of children's lives that have been saved by the use of a more effective drug than CQ during this period. Being prepared Realising however that at some stage in future SP will have to give way to another more effective drug or combination of drugs, the Programme is encouraging research in this area of alternatives to SP; one of the most advancedprojects has been the study of Chloryroguanil-Dapsone or LAPDAP at Ndirande Health Centre (Blantyre). We are also looking at the possibility of studying compounds containing the artemisinin derivatives since WHO now recommends moving towards what is referred to as Combination Therapy or CT. This approachdraws on the experienceof treatment of malignancies,TB and HIV infection - it is designed to reduce the chancesof a parasite developing resistance by using two or more drugs that have independent modes of action and different biochemical targetsin the parasite. Using this definition, SP does not qualify as CT. The National Malaria Control Programme is also concemed about optimising the uptake of IPT-SP becausethere is now evidence that nationally only about 3'77oof pregnant women are taking the full two dosesof SP in spite of high antenatalclinic attendanceand also good knowledge about both the IPT regime and the safety of SP
This issue of Malawi Medical Journal was supported by a generousdonation from the Centers for Disease Control (CDC), Atlanta, Georgia,USA, and by the Blantyre Integrated Malaria Initiative (BIMI), Blantyre, Malawi.
in pregnancy. Another problem is the mounting evidence that women who are HIV infected require more than the two doses of SP to achieve the same benefit of reduction of placental malaria and consequentreduction in LBW as those women who are not HIV infected. Studies will soon be underway to address this issue. Working together In conclusion, it is important to remember that Malawi has contributed significantly to the international malaria control efforl by sharing her experience in managing a national antimalarial drug policy change. Malawi has also contributed a large body of knowledge in managing malaria in pregnancy and in the management of severe malaria - IPT-SP and the Blantyre Coma Score are visible such contributions. The articles in this edition of MMJ are further testimony of the excellent work done in this field. The history of malaria control in Malawi has been one of policy driven by locally generatedrelevant scientific data and this has been made possible by the good working relations between researchers and programme implementers. We will continue to nurture this relationship, which is ultimately beneficial to our people. Peter N Kazembe Chairman, M alaria Control Committee
Calls for papers
SpecialHIV - AIDS issueof MMJ GuestEditor Dr John Chisi The next issueof MMJ will focus on HIV - AIDS. You are warmly invited to contribute material of anv of the followine kinds: o o a o o o a a
Personalview Casereport Descriptionof a programme Scientific article (researchor audit) Letter to editor Conferencereport Poem other
Submissionsshould reachthe Guest Editor by 30 July 02. Pleasesubmit either as e-mail attachmentto [email protected] Or as paper copy with accompanying diskette,addressedto Dr John Chisi, College of Medicine,PlBag 360, Blantyre
\l:lagi
Medical Joumal
