contain + eliminate = no parasite

Archive for the ‘Counterfeit and substandard drugs’ Category

Dr. Char Meng Chuor: ‘We Need Community Support to Eliminate Malaria’

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CONTAINMENT recently spoke to Dr. Char Meng Chuor the new Director of the National Center for Parasitology, Entomology and Malaria Control (CNM).

Dr. Char Meng Chuor. Pix by WHO/sonny krishnan

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.


Customs Department Backs Malaria Elimination Plan with Zero Tolerance for Counterfeits

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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.

Em Khin Vorac, Deputy Director General, Department of Customs and Excise. PIX by WHO/Sonny Krishnan

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.

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Written by malariacontainment

June 29, 2011 at 11:21 am

The Battle to Contain Resistance

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CONTAINMENT recently spoke to Dr. Robert Newman, Director of WHO’s Global Malaria Program, who was on a field visit to Pailin in Western Cambodia.

Dr. Robert Newman, director of WHO's Global Malaria Program. Pix by WHO/Sonny Krishnan


There is a long history in malaria control efforts. What’s different now and how has the landscape changed?

Obviously the big issue here right now is the emergence of resistance to artemisinins and this is not just an issue along the Cambodian – Thailand border, but is also a global issue. We rely very heavily on artemisinin-based combination therapies or ACTs and artemisinin is the key ingredient in that combination.

And the stakes are very high because right now we do not have other drugs in the development pipeline that are likely to reach markets before five years, the earliest. And that is an optimistic projection.

So it is really critical that we bring all forces together to try and preserve the efficacy of these valuable medicines.

Here in Western Cambodia we have an extraordinary effort made by the Cambodian National Malaria Control Program and their counterpart program in Thailand to contain the spread of these resistant parasites. The efforts here, I think, have been groundbreaking in their comprehensiveness. Some of the approaches that have been taken are also novel and pioneering.

The Cambodian government has banned the sale of monotherapies. Do you think there should be a similar ban regionally within the Association of Southeast Asian Nations or ASEAN?

Absolutely. I think we all agree now at this point that the use of oral artemisinin monotherapies is probably the single greatest factor for the spread of artemisinin-resistant parasites. In 2007 there was a World Health Assembly resolution that called for a halt in the marketing and use of these compounds.

The worst case would be the spread of the delay in clearance of the [plasmodium] parasites. Right now we are finding an increase in the percentage of patients who are still positive on Day 3. That will be the hallmark of this problem [of resistance]…

While there has been some forward movement in the number of countries that have complied both in terms of shutting down the manufacturer, marketing of these drugs and to some extent in their use, we still have to go some way. This is such an urgent issue. The time to do that is now.

We need all countries, globally – particularly here in the Greater Mekong sub-region and ASEAN to ensure that these dangerous medicines are removed immediately from the market place.

What are the differences between containment and elimination; elimination and eradication?

Containment would mean in this context that we take these resistant parasites and don’t let them spread outside the area where they have been identified. So at this point the confirmed areas are along the Thai-Cambodian border, although there are other areas in the Greater Mekong sub-region where we have suspicion of their emergence.

Elimination would mean that we would actually be able to eliminate all of the parasites. That is a very difficult thing to document. Obviously, if we are able to eliminate these resistant parasites then the risk of their spread is essentially gone.

The term elimination is more generally used to refer to the reduction at the country level of local transmission of malaria to zero. So usually we talk of eliminating malaria at a country level.

Eradication is reserved for the global incidence of malaria going to down to zero. And that’s for all plasmodium species and not just for falciparum. That obviously remains the ultimate public health goal, although I believe that will take 40 or more years to achieve. It would require the development of new transformative tools that we do not have, yet.

What’s the worst case scenario for MDR-falciparum malaria?

The worst case would be the spread of the delay in clearance of the [plasmodium] parasites. Right now we are finding an increase in the percentage of patients who are still positive on Day 3. That will be the hallmark of this problem [of resistance].

If that were to continue to worsen, artemisinins would become less and less efficacious. It would then take longer and longer for patients to clear [plasmodium parasites in their blood], and we could get to the point of truly having failures to ACTs.

Right now we have resistance to artemisinins, but artemisinin-based combination therapies (ACTs) still remain efficacious. That is a very important message.

But if that situation worsens, if were to lose ACTs, and if it spreads to the shores of Africa, we could have a public health catastrophe.

As you know we still have more than 700,000 estimated deaths a year in Africa from malaria. We rely entirely on ACTs for the treatment of falciparum malaria. If we were to lose those medicines in Africa, that would be a catastrophe. This is precisely what the extraordinary efforts in the Containment Project, here, in the Greater Mekong sub-region are trying to prevent.

Lessons Learned from Cambodia Useful for Region

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Cambodia Task Force Meeting in progress. Pix by WHO

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…

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Written by malariacontainment

December 27, 2010 at 3:20 pm

A Day in the Life of a Pailin Drug Inspector

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CONTAINMENT’s Moeun Chhean Nariddh follows Justice Police Officer Nuth Tith on his rounds in the Pailin market in North-West Cambodia.

Justice Police Officer Nuth Tith inspecting a Pailin pharmacy's display cabinet. Pix by WHO/Moeun Chhean Nariddh

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.”

Written by malariacontainment

November 25, 2010 at 11:01 am

Law Enforcers to Get Tough on Counterfeit Medicines

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Police officers in Siemreap at the nationwide training to crackdown on counterfeits. Pix by WHO/Sonny Krishnan

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.

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November 24, 2010 at 10:52 am

Affordable ACTs For All Cambodians

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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.

Dr. Kheng Sim, Vice-Director of CNM. Pix by WHO/Sonny Krishnan


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.

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November 14, 2010 at 9:50 am