Required Testing for Malaria Will Save Lives and Money

31 Mar 2010
Daily Nation
A new requirement by the World Health Organisation that all suspected malaria cases be tested before medication is welcome, and the government must move with speed to implement it.

Kenya adopted, and is still using the previous WHO guidelines, which dictated that all fevers among children below the age of five be treated as malaria without diagnosis.

But a recent research in Nairobi's Korogocho slums appearing in the Malaria Journal clearly indicates that the guideline had a tragic loophole.

The study conducted by the African Population and Health Research Centre, among others, screened 983 people who had gone to Korogocho health centres with fevers, and none was found to be malaria-positive.

Yet most had been given anti-malarial drugs or a prescription in respect, with the existing policies.

The research by no means declares Nairobi a malaria-free zone. But it is a clear message that Kenyans are being given expensive anti-malarial drugs for wrong reasons.

This is likely to compromise their immunity, and the malaria parasite is likely to develop resistance.

At the same time, the recommended drugs for malaria treatment in Kenya (Artemisinin Combination Therapy - ACT) cost about Sh500, which is expensive for slum residents, and a loss to the government and donors in cases of free treatment.

In the 1950s, quinine was the ultimate drug used to manage malaria. But, health researchers developed another drug to manage uncomplicated malaria, so that quinine was preserved for complicated malaria.

As a result, evidence shows that through the controlled exposure of quinine, the drug is still highly effective.

To replace quinine, amodiaquine drugs were developed for management of uncomplicated malaria. The drug was extremely effective to a point that many Kenyans still live with memories of chloroquine and malariaquine tablets, with the popular dose of 4-2-2-2.

But existing policies allowed the drugs to be sold across the counter, thus over-exposing them to people who could self-prescribe for fevers suspected to be malaria.

At the same time, its bitter taste made people genuinely suffering from the disease abandon the dose half-way, once they felt better, or because of side effects. As a result, the malaria causing parasite developed resistance.

This paved the way for a new generation of anti-malarial drugs known as Sulpadoxine-Pyremethamine, commonly referred to as SP.

As if we had not learned any lesson from the previous experience, the drugs were in retail shops for anybody suspected to be suffering from malaria, often without diagnosis.

Many still recall Metakelfin and Fansidar; the malaria parasite mounted resistance against them within a very short time, rendering them useless for malaria treatment.

Luckily, the Chinese discovered herbal medicine from a Chinese plant called artemisinin. Studies found it to be highly efficacious against malaria, prompting the WHO to adopt it. Thus, a combination of this drug with any other is to date the recommended treatment for malaria.

But once again, nobody looked at past experience; hence a policy guideline was issued indicating that all fevers in children be treated as malaria using the drug without necessarily diagnosing them.

This WHO guideline, which has been adopted by several countries -- Kenya included -- existed until a month ago, when it was revised to include diagnosis as an important package in malaria management.

This sounds like a real challenge because the ACT drugs are already overexposed in the market, perpetuated by proliferation of several ACTs through the liberalised market, some efficacious, and others counterfeit.

As a result, the possibility of the disease mounting resistance against them is high, making the war against the killer disease fiercer.

To arrest the situation, all malaria suspected cases must be diagnosed and fully treated. This means the Drug and Poisons Board must also move with speed and control importation of anti-malarial drugs, to avoid the possibility of one buying counterfeited or uncertified drugs.

Any delay to implement this has a high likelihood of the only available remedy developing resistance, as it has done in Cambodia, where malaria is already tolerating artemisinin, an important component of the ACTs.