Posts Tagged ‘ACTs’
CONTAINMENT’s Nat Sumon accompanied an Armed Forces Medical Research Institute for Medical Science (AFRIMS) mobile unit to a remote location on the Thailand side of the border to screen soldiers for malaria.
Over the course of history, in times of war, more soldiers have died from malaria than in direct combat. During the Vietnam War (1962–1975), malaria felled more combatants during the war than bullets. The disease reduced the combat strength of some units by half.
Over 40,000 cases of malaria were reported in U.S. Army troops alone between 1965 and 1970 with 78 deaths. The U.S. Army established a malaria drug research program when U.S. troops first encountered drug resistant malaria during the war. In 1967, Chinese scientists set up Project 523 – a secret military project – to help the Vietnamese military defeat malaria by developing artemisinin based anti malarial formulations.
For the Thai army, malaria still remains a threat despite the drastic fall in cases of falciparum malaria – the most fatal form of the mosquito-borne disease. According to 2010 Royal Thai Army statistics, 572 soldiers contracted malaria along the Thai-Cambodian border and constituted one-fourth of overall malaria patients seeking treatment in the area.
Many Thai soldiers used to harsh tropical jungle conditions are well aware of protective measures. If they fall sick, they are instructed to go either to local malaria clinics or local hospitals to have their blood tested on a weekly basis.
CONTAINMENT recently spoke to Dr. Char Meng Chuor the new Director of the National Center for Parasitology, Entomology and Malaria Control (CNM).
One big concern is malaria on the move. How important is the role of village malaria workers or VMWs in the early diagnosis and treatment of mobile migrant workers?
Yes, indeed, malaria on the move among mobile migrant workers is worrying. But first let me clarify one thing on terminology. I like to refer to the village malaria workers as community health workers because they can also work on other diseases at the community-level. At present in each health centers there are only seven to eight full-time health staff as first-line health workers. And as you know most of the villages are far from the health centers. So we need these community health workers to support the work of the health centers.
When Khmer people fall sick, they end to seek treatment from the nearest source available to them. And most often, these community health workers are nearest to them. For that reason they are so important in the fight to contain multi-drug resistant malaria. These community health workers not only carry out early diagnosis and treatment, but they also provide vital information to the mobile migrant workers on how they can protect themselves against malaria.
Counterfeit and substandard anti-malarials are one of the causes for the emergence of MDR-falciparum malaria. What are the efforts to eliminate these counterfeit and substandard drugs sold by the private sector and also enforce the ban on oral artemisinin monotheraphy?
First of all, we have to ensure that communities must have access to genuine medicines. This is essential. We can ban oral monotherapies, but if sick people do not know where to get effective anti-malarials, we will go back to square one. Secondly I need to emphasize the importance of law enforcement. The elimination of malaria by 2025 is a government priority and so it’s important that legislation is in place for the law enforcers to start the crackdown of counterfeit malaria medicines.
But let us not forget that we have to also work with the private sector through partnerships. We are now drafting the strategy for the public-private mix, in terms of malaria. We’re still in the learning process, when it comes to dealing with the private sector. But there’s a lot of donor goodwill to provide technical assistance. The chink in the armour is the private sector because most Khmers when they fall sick go to the pharmacies or drug stores first. We have to convince the private sector on why they need to be good and responsible providers to prevent a public health emergency that could cross borders.
What are the lessons learnt from the Containment Project, and how can these lessons be used as we move from malaria control to elimination?
CNM has been implementing the containment project since January 2009, and we have many lessons to share. The first and most important lesson is that it is possible to reduce malaria incidence in the target zones through good management and implementation of proven strategies in malaria control, such as high-level coverage of long-lasting insecticide treated bed nets, provision of free diagnosis and treatment at the community level, and engagement of the community through malaria education and awareness programs. CNM, through the support of the Bill and Melinda Gates Foundation and the assistance of technical partners such as WHO, Institute Pasteur and Malaria Consortium, and others, has helped us achieve this.
We have also found that, when malaria cases begin to decrease, the role of systematic gathering of health information, including malaria surveillance and response becomes very important. As malaria cases decrease in Cambodia and we are on our path towards elimination, we need to strengthen surveillance systems to capture information on cases up to the village level, and also concentrate on responding to increases in cases through distribution of bed nets and indoor residual spraying.
Another lesson learned is the need to engage and work closely with the private sector in order to be informed of those malaria cases treated by the private sector, in pharmacies and private clinics, and to provide incentives to the private sector to help in the fight against the sale and manufacture of artemisinin monotherapies, as well as fake and substandard drugs.
Also, we need to be sure to have the full support and participation of communities in the fight against artemisinin-resistant malaria, and also move towards elimination. This can be facilitated through wide-ranging media awareness campaigns, community mobilization through local community organizations and distribution of information, education and communication materials, as well as advocacy by involved leaders and authorities.
Em Khin Vorac, Deputy Director General, Department of Customs and Excise of the Government of Cambodia, speaks to CONTAINMENT’s Moeun Chhean Nariddh in Phnom Penh.
How is the General Department of Customs and Excise involved in the fight against counterfeit products and medicines?
With support from the Mekong Priority Solidarity Fund Project, coordinated by the French Embassy, we are active partners with other project members including the Ministry of Interior. We have had a number of meetings and workshops on the joint crackdown on counterfeit products and medicines. Our Customs officers are now positioned at different checkpoints along the land borders with Thailand, Vietnam and Laos. Most of the counterfeits, originating from neighbouring countries, seem to be getting through these checkpoints and for this reason we have increased the number of Customs personnel at these border crossings.
Our Customs officers remain vigilant. Some of these counterfeit medicines are smuggled through in small quantities in people’s handbags. Sometimes, they conceal them with lawful goods. For example, they might conceal about ten small cantons (of counterfeit medicines) with sacks of cement, piles of iron, boxes of cakes and sweets and other items where Customs duties have been paid. Under such circumstances it can get difficult to check all items coming into the country through these land borders.
The lessons learned from the feedback at the meeting of the National Task Force of Cambodia will be useful to other countries in the Greater Mekong Sub-region in the push for a regional containment agenda towards the elimination of artemisinin-resistant falciparum malaria.
This was the message put forward by the Secretary of State for the Ministry of Health, His Excellency Chou Yin Sim, when he opened the third Cambodian Task Force meeting on December 3, 2010 at the Phnom Penh Hotel.
“The National Task Force of Cambodia provides national supervision to the Containment Project funded by the Bill & Melinda Gates Foundation,” he told the meeting attended by WHO, the National Malaria Control Centre (CNM), and their working partners.
“Elimination of resistant malaria parasites will remain out of reach unless we pay adequate attention to the delivery of health services, including good surveillance of remote areas and migrant populations. This cannot be done without the strengthening of health systems,” stressed H.E. Yin Sim.
H.E. Yin Sim pointed out the strategies that have been effective in the Containment Project.
“The strategies that have been found to be effective in the Containment Project have been the provision of free diagnosis and treatment by village malaria workers and the promotion of the use of LLINs (long-lasting insecticide treated nets) by populations at risk of malaria, especially those who stay overnight in the forest,” he told the meeting.
Another important strategy was the ban on monotherapies that H.E. Yin Sim said had proven to be effective in addressing the spread of multi-drug resistant falciparum malaria.
“The Ministry of Health is committed to eliminating monotherapies and perpetrators will be subjected to administrative measures and legal action,” he said.
“In Cambodia, a ban on monotherapies together with the Public-Private Mix initiative have achieved almost zero prevalence in artemisinin monotherapies as well as a significant reduction in fake and substandard drugs on the market,” said H.E. Yin Sim.
“I do hope this positive example and the lessons learned can be replicated in other countries in the region,” he emphasized.
To reduce drug pressure we also have to engage the private sector – it’s a partner we have to engage with and we are trying work with them and develop strategies to do so…
CONTAINMENT’s Moeun Chhean Nariddh follows Justice Police Officer Nuth Tith on his rounds in the Pailin market in North-West Cambodia.
It’s almost noon now in Cambodia’s Pailin province on the northwestern border with Thailand. Nuth Tith, a middle-aged health official, quickly changes his clothes and wears a new police uniform.
With a light blue shirt and dark blue trousers together with a sky blue cap, Nuth Tith looks no different from other police officers.
The only difference is that the sign on his shirt is a medical symbol instead of the normal Singha, or King of Lions, emblem used by other national police officers. Another thing is that he does not have a revolver in his belt and neither does he carry handcuffs.
Yet, he is not a normal policeman.
Trained as one of the five justice police officers in Pailin, Nuth Tith’s duty is to inspect pharmacies and drug stores to make sure that no counterfeit or substandard malaria drugs are on sale.
He is now ready to carry out his tasks.
After a ten-minute ride from the provincial hospital, he hops out of the car and rushes to a line of drug stores at a small market near Pailin.
“Do you have any malaria drugs left?” he asks Phat Sambo, a 28-year old drug seller at the front row.
“No!” she replies, laughing.
He searches the drug cabinet but finds no malaria drugs on sale.
“Now, put these flyers on the wall and don’t put any other pictures,” he advices and hands out a few anti-malaria drug flyers to Sambo.
Nuth Tith says the justice police officers would inspect the pharmacies and drug stores every three months as part of the efforts to stop the sale of malaria drugs and other fake and substandard medicines.
He explains that if the justice police find any counterfeit drugs, they will confiscate them. But he adds that a justice police officer has no power to arrest anyone found in possession of malaria drugs or other counterfeit and substandard medicines.
The drug inspector says that in the malaria containment project, funded by the Bill & Melinda Gates Foundation, drug sellers from Pailin and other remote areas had been invited to a workshop where they were trained by officers from the Ministry of Health and the National Centre for Parasitology, Entomology and Malaria Control or CNM. Tith says they received lectures on the dangers of artemisinin-resistant falciparum malaria spreading globally and were encouraged to help eradicate malaria altogether.
“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.
Now, the drug inspector has got back into the car and moved to the pharmacies in Pailin market. He stops by a pharmacy run by 36-year-old Sor Pov, who’s been selling medicines for the past eight years.
When asked if she has received any patients who have come to buy malaria medicines, she replies that only about one in every 100 people have asked for malaria drugs at her store.
Duch Vanda, a 43-year-old vendor who sells medicines at a pharmacy next to Sor Pov’s, agrees that the number of people seeking malaria medicines has sharply declined.
“Now, almost nobody asks for malaria drugs,” he claims.
As instructed by the justice police, both Sor Pov and Duch Vanda say they would refer any malaria patients to get free treatment at the health centers around Pailin, if any customer asks to buy malaria medicines.
Sambo says the justice police officers have visited her store five times now since she started selling drugs two years ago.
“I think the anti-malaria campaign has been very successful, because there are no more malaria patients,” Sor Pov points out.
Drug inspector Nuth Tith then continues to the last pharmacy in the same row at Pailin market. But, he still cannot find any malaria or other fake drugs either.
Tith says that since he started his new drug inspection job three years ago, he has found less and less malaria drugs in the 25 pharmacies and drug stores he constantly inspects in Pailin.
After visiting the last pharmacy, Nuth Tith returns to the provincial hospital with a smile, proving that his work has been a success.
“[In the past] there were a lot of malaria drugs on sale,” he recalls. “Now, we hardly find any malaria medicines.”
Cambodian malaria experts and senior police officers have agreed that better cooperation and concerted efforts are needed to effectively combat malaria as well as curb the sale and smuggling of counterfeit and substandard drugs in Cambodia.
“The Ministry of Health has done a lot of work, but it would not be able to do anything without the cooperation of the police,” explained General Ben Rath, Vice Commissioner for Phnom Penh Municipal Police, during a workshop on “Strengthening Law Enforcement for Investigation of Counterfeit Medicines and Artemisinin Monotherapy”, which was held in Siemreap Province from November 10 to 12, 2010.
The National Centre for Parasitology, Entomology and Malaria Control or CNM that receives technical assistance from WHO, with support from the Global Fund and in cooperation with the Ministry of Interior organized the three-day training of trainers’ workshop for 55 senior police officers from 24 cities and provinces across the country. The workshop was to improve the investigative skills of the Cambodian senior police officers to identify and crackdown on fake and substandard malaria drugs that have been smuggled and sold in the country.
Dr. Kheng Sim, Vice-Director of Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) speaks to CONTAINMENT on efforts to make vital anti-malarial drugs available to Cambodians at affordable prices.
Cambodia has been chosen for the Affordable Medicines Facility – Malaria (AMFm) Phase 1. The lessons learnt from AMFm’s Phase 1 will be used for Phase 2. Can you tell us how programs have been put in place, in Cambodia, to subsidize the cost of Artemisinin Combination Therapies (ACTs) and make them widely available for a lower cost, which should help eliminate the black market for counterfeit drugs.
Firstly I have to state that Cambodia’s application to AMFm was approved this year. CNM, together with other licensed importers, is now eligible to access ACTs at a greatly reduced price through subsidies from the Global Fund. When all parties agree on the ACT that is to be used nationally, one that also meets the requirement of the Global Fund quality standard, CNM and the private importers can procure these products at approximately 5% of the manufacturer’s sale price.
However the actual ACT co-payment is determined through negotiations between the Global Fund appointed agent and the manufacturer. Nonetheless due to the unique situation of emerging artemisinin resistance in Cambodia, there have been challenges to identify an appropriate ACT that is also eligible to be subsidized.
The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured artemisinin-based combination therapy.
Universal access to effective malaria treatment is among the United Nations’ Millennium Development Goals. This also is among the goals of the Roll Back Malaria Partnership.
In spite of high-level commitments, political will and substantial increases in financing, the attainment of this goal has remained elusive in most malaria endemic countries, especially in relation to artemisinin-based combination therapy (ACT), the treatment recommended as first-line by the World Health Organization (WHO) for uncomplicated malaria caused by Plasmodium falciparum.
The Affordable Medicines Facility-malaria (AMFm) is a new financing mechanism to expand access to effective malaria treatment. A response to the dual challenge of poor access to quality-assured anti-malarial medicines and threats of parasite resistance to treatment, the AMFm combines price negotiations with a factory-gate buyer subsidy to reduce the price of ACT.
The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives. These objectives include replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin.
The AMFm is hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. The pilot phase of the programme, which includes Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, the United Republic of Tanzania and Uganda, is scheduled to last from 2010 to 2012.
The AMFm is funded from multiple sources including a co-payment fund of US$216 million, financed by the Bill & Melinda Gates Foundation, the UK Government, and UNITAID. In addition, the Global Fund provides US$127 million to fund supporting interventions at the country level.
Enabling appropriate and rational use of ACT
To preserve the effectiveness of ACT over time, it is important that these life-saving medicines are used appropriately. A number of studies have shown that malaria case management, particularly in the retail sector, is unsatisfactory.
The private sector, in particular drug outlets, should be supported and capacitated to provide appropriate and rational management of malaria. Integrated approaches aimed at improving understanding and treatment of malaria can lead to tangible improvements in management of malaria. Building on lessons learned so far, the AMFm will work with countries and technical partners to build the skills of drug shop attendants using promising models, such as the Tanzania Accredited Drugs Dispensing Outlets (ADDOs).
Regulation can play an important role in enhancing access to ACT and improving the quality of care. A number of studies have reported that subsidizing ACT may need to be supported by effective regulatory policies for the intervention to be effective in crowding out less effective anti-malarials from the market. Countries in AMFm Phase 1 may use funds from the Global Fund to strengthen in-country regulatory systems.
Related to regulation is product quality. The AMFm will work with partners to adopt policies that assure product quality. For instance, AMFm uses the Global Fund’s quality assurance policy, which requires the procurement of WHO-prequalified products and those that have passed stringent quality assessment. Product branding serves to establish bonds among buyers, sellers and products. In many malaria-endemic countries there are various products available for the treatment of malaria. The availability of a wide range of products can makes it harder for buyers to distinguish quality-assured products from others. ACT under the AMFm will bear a distinct logo that will serve as an identifier and sales driver.
Finally, it is important to expand access to the parasitological confirmation of malaria, with a view to ensuring that only those who have malaria receive ACT as treatment. Most cases of presumptive treatment with ACT take place in the private sector. In the near- to medium-term, it is highly unlikely that effective public sector services will replace the private sector in most malaria-endemic countries.
Therefore, universal access to diagnostics requires the achievement of universal access to these technologies in the private sector. Given the new WHO’s normative guideline on the goal of universal access to diagnostics, it is important to identify the most suitable financing mechanisms for expanded access to diagnostics in the private sector, and to better understand the most feasible ways of expanding the use of diagnostics, particularly in the formal and informal private sectors.
The operations research elements of AMFm Phase 1 provide opportunities to learn how to increase coverage of diagnostics in the private sector in a way that can inform scaling up to universal access.
This is a condensed open-access article “The quest for universal access to effective malaria treatment: how can the AMFm contribute?” written by Lloyd Matowe and Olusoji Adeyi that was published in the Malaria Journal 2010, Vol 9, issue 274.