Therapeutic efficacy of anti-malarial drugs in Afghanistan

Najibullah Safi, MD, MSc. HPM, DMPPMPrimary Health Care Advisor

WHO - Afghanistan

Outline of the presentation

General information about malaria in Afghanistan

Aim, method, results, conclusion and recommendation of the study (therapeutic efficacy of anti-malarial drugs in Afghanistan)

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Introduction

Major determinant of malaria transmission in Afghanistan are:

- Altitude (below 2000m above the sea level)- Agriculture (rice cultivation)

Three strata- First stratum: medium to high transmission- Second stratum: low transmission- Third stratum: has less potential for malaria

transmission

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Malaria transmission in Afghanistan

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Strategies for malaria control

Prompt diagnosis and effective treatment Vector control and malaria prevention, in the

framework of IVM more focusing on LLINs IEC/BCC Health system strengthening Timely detection and control of malaria

epidemics

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Anti-malarial treatment in health care system of Afghanistan

Health post (HP) Basic health center (BHC) Comprehensive health center District hospital Provincial hospital Specialized hospital

Clinical MalariaClinical MalariaClinical MalariaClinical MalariaClinical MalariaClinical Malaria

Confirmed Malaria

Clinical Malaria

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Study aim, method, results, conclusion and recommendations

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Background

Malaria is endemic with seasonal transmission in Afghanistan

Incidence exhibits a bimodal pattern– Peak of Vivax in July and August– Peak of Faciparum in October

Since 1940s cholorquine has been used widely in the treatment of malaria, and remains first line therapy for the treatment of confirm PV

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Background cont.

In 2002, PF malaria comprised 20% of all reported cases

Spread of chloroquine resistance was likely to be contributing factor to the increase of PF cases

Chloroquine resistance was first reported in 1986

In 1999, a study reported 67%treatment failure in the east of the country

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Background cont.

Access to effective malaria treatment is a cornerstone for malaria control program

To guide the development of national malaria treatment guideline , anti-malarial drug efficacy data is needed

In 2003, four sentinel sites were established to monitor the efficacy of anti-malarial drugs

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Sentinel sites for efficacy study

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Aim, Patients and Methods

Aim: to monitor the efficacy of anti-malarial drugs and guide the formulation of National Malaria Treatment Guideline

28 days in vivo efficacy study Study subjects recruited from patients

attending clinics for febrile illness

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Patients and Methods cont.

Inclusion criteria:– Fever in past 24 hours– Over 6 months age– Giemsa stained positive slide for PF, mono

infection with parasite density of 1000-100000/l

– Live within one hour car journey of the centre– Informed consent

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Patients and Methods cont.

Exclusion criteria– Any sign of sever disease– Pregnancy– Currently in treatment for malaria– Febrile disease other than malaria

Follow up: parasitological follow up on day 2 and parasitological and clinical follow up on days 3, 7, 14, 21 and 28

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Outcome

Early treatment failure if:– On day 1-3 patients suffered from sever illness, or if on

day 2 parasitaemia was greater than enrollment day– Persistent fever in the presence of parasitaemia on day

3 Late clinical treatment failure if:

– The patient suffered from auxiliary temperature ≥ 37.5°C on day 4-28

Late parasitological failure if:– Parasitaemia, without symptoms, was recorded on days

7-28

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Summary result of the study

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Conclusion and recommendations

SP + Artesunate remain efficacious The combination has the advantage of being

clinically efficacious as well as delaying the development of resistance

The combination may decrease transmission because of gametocidal effect of Artesunate

Chloroquine is still effective for the treatment of Vivax malaria

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Conclusion and recommendations

To continue up-dating the national treatment protocols of malaria, the 3 sentinel sites should be maintained and provided with adequate technical capacity to continuously monitor the therapeutic efficacy of antimalarial drugs in Afghanistan

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