Articles for March 2005

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Recently, Nigerians got conflicting signals on the state of healthcare as it relates to the use of chloroquine as the first line drug in the treatment of malaria. But in a chat with reporters in his office, Minister of Health, Prof. Eyitayo Lambo, said there was no cause for alarm.

The conference room of the Minister of Health, Prof. Eyitayo Lambo, was bristling with journalists and other stakeholders in the health sector. The issue had been a burning one and had become thorny of recent. The gathering on that fateful morning was to thrash the controversy surrounding the banning or otherwise of chloroquine as the frontline drug in the treatment of malaria in the country.

Sequel to an interactive meeting which involved officials of the Federal Ministry of Health, the Roll Back Malaria Partners and the representatives of the Pharmaceutical Manufacturers Group of Manufacturers Association of Nigeria (PMG-MAN) in January, the minister was reported to have banned chloroquine in the country owing to its increasing ineffectiveness in malaria treatment. Lambo had called the media and other partners to douse the rumour that chloroquine had been dumped as a frontline drug in malaria treatment and replaced with the Artemisinin - based combination Therapy (ACT).

Although the ACT's efficacy is not in doubt, the prices are out of the reach for most Nigerians since they are sourced through imports. This led to an avalanche of protests from some professional groups and ordinary Nigerians that a chloroquine ban would be synonymous with throwing the baby away with the bath water.

But at the briefing, the minister said while awaiting a malaria vaccine, case management with prompt and effective treatment remained the mainstay of malaria control. "Indeed, effective case management is a key strategy of the Roll Back Malaria Initiative aimed at reducing morbidity and mortality. Hence, the effectiveness of the strategy depends critically on the availability and access to safe and efficacious anti-malarial drug treatment", he stressed.

The minister noted that evidence have shown that the first line anti-malaria drug, chloroquine, has lost it efficacy due to the emergence of chloroquine-resistant parasite strains. This trend, he said, was first noticed in 1987 in the south-eastern part of the country, and has since extended to other geo-political zones in Nigeria.

Lambo stated that the result of the drug efficacy studies, conducted in 2002 in six centres across the six geo-political zones of Nigeria showed treatment failures up to levels that necessitated the drug policy review. He said the test estimated the efficiency of the drug in clearing malaria parasite from the blood system and thus the response of the patient to the drug.

According to him, the national average for efficacy of chloroquine is 39.2 per cent, implying 60.8 per cent failure rate of the drug. This meant that for every 10 people treated with chloroquine, only four people will be cured with the drug

In the result, efficacy of chloroquine in the South East zone was put at 3.7 per cent, 9.1per cent in South South, 40.9 per cent in South West, 50.8 per cent in the North East, 53.2 per cent in the North Central and 77.3 per cent in the North West. He said only the North West zone meets the WHO recommended level of efficacy i.e. no less than 75 per cent for national drugs, which in this case is chloroquine.

Lambo stated that at this level of failure, it would be unethical to maintain chloroquine as first line drug for the treatment of malaria in Nigeria. "Sulphadoxine Pyrimethamine i.e. Fansidar, another popular first line drug, is also not spared. The efficacy level is as low as 14.9 per cent in the South East though still above WHO recommended level in three zones. Based on these tests therefore, we have no choice but to change the first line drugs in the interest of our people", he said.

Based on these facts, a proposal for a change was therefore made and the Artemisinin - based combination Therapy (ACT), he said, was considered in line with the practice in other malaria endemic regions of the world. According to him, the world is a global village and the resistance of malaria parasite to chloroquine has been spreading over the years- from Asia to East Africa, Central Africa, South Africa and now to West Africa.

The policy review, which he said remained a proposal, is premised on the need to protect the people, especially the most vulnerable - under-5s and pregnant women - against the scourge of malaria.

On the present status of chloroquine, Lambo was emphatic: "I did not say anything about banning chloroquine in my remarks during the interactive meeting. Chloroquine is still efficacious in the North West zone of this country. But you will agree that a situation where there is a 60 per cent failure rate of the drug in five out of sixzones, it is not safe to recommend it as a frontline drug in a national policy for treatment. Just as there are currently other anti-malaria drugs in the market, so it is envisaged that when the new policy is implemented, there will still be other anti-malaria drugs available including chloroquine and sulphadoxinepyrimethamine".

He said the process of malaria treatment policy change is gradual, lasting over a period of time and usually involves three phases. These include, the policy change proposal phase, which involves processes and procedures leading to the selection of the proposed new treatment. The transition phase comes after the decision on the new treatment policy has been made and the full implementation phase will involve the national rollout of the new policy.

He assured partners in the pharmaceutical manufacturing industry that they would be represented on the committee for the implementation of the policy. "It is in the interest of the country to involve them. We want to build our capacity to manufacture locally up to 80 per cent of the drugs consumed in this country locally. This is what will ensure affordable costs and sustainability of our programmes", Lambo stated.

The minister noted that they were aware of the high cost of ACTs at the moment. He said government's propping of the pharmaceutical industry remained the panacea to issues of cost.

"In the interim, we are benefiting from the Global Fund to Fight HIV/AIDS, tuberculosis and malaria with the provision of free ACTs to treat about eight million children under five years of age. This is based on the estimation of two episodes of malaria attack per year. With the free ITNs for this group, we are confident that their episodes will reduce from the estimated four to two per year. This is an opportunity for us to provide efficacious drugs for our children in the interim", he said further.

He said the ministry was determined to reduce the disease burden attributable to malaria. He promised to promote the use of insecticide treated bednets and also implement strategies that are geared towards vector and environmental control. More aggressive public enlightenment concerning malaria, he said, would also be pursued.

Virtually all the directors in the ministry, officials from partner agencies like Dr. Bayo Fatunmbi, RBM Coordinator, WHO, Abuja, Dr. Akudo Anyawu, advisor, Global Fund Mechanism, Dr. Ibrahim Alhaji Umar of the Yakubu Gowon Centre and Mr. Nnamdi Okafor, chairman, PMG - MAN, among several others, were present at the ceremony.

In her remarks, Dr. Eudogie Abebe, director, public health of the Ministry of Health said chloroquine still remained a therapy in the management of malaria. "The fact that the minister says ACTs have been adopted as the first line drugs for malaria treatment does not mean that we have banned chloroquine as first line drug. It only means we have stopped using it as the first line drug and I believe that is where the confusion came from. Chloroquine is not banned whether as first line drug or as any other drug. It is not banned. We are no longer using it as the first line drug as a national policy".

According to Abebe, a national policy entails addressing the whole nation and not only a section. "When drawing up a policy, you look at what involves the common good of the people of the nation and that is why at that failure rate, even though chloroquine is still effective in a zone, we cannot say the North West should continue to use it while others do not. We can't do that", she added.

She said the new malaria treatment policy, was still within the realm of a proposal, adding that it has not even been taken to the Federal Executive Council.

Okafor re-emphasised that given enough time (two years), the pharmaceutical companies would be able to cope with the demands of the policy. He said they were aware of the failure of chloroquine and that the ACTs have become drugs of choice in the management of malaria.

Dr. Kayode Omotayo, director, drug and food services of the ministry, stated that NAFDAC would do everything to ensure that faking was nipped in the bud. He said the transition committee to be set up by the ministry on the policy would take care of issues like affordability, efficacy and related matters.

This Day (Lagos,Nigeria)