E-DRUG: artemisinine combinations for malaria
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[Seems that the malaria world has finally agreed that artemisinine
combinations are the way to go. However, it is a plant that needs to grow.
Who will ensure that farmers grow enough plants this year so that we have
enough treatments next year? Below are two articles on the MSF Malaria
Symposium in NYC last week; copied as fair use. WB]
The troubling fight against old killer
By Steve Sternberg, USA TODAY
The Chinese call their sweet wormwood extract Qinghaosu. Chemists call it
artemisinen. The Zulu are so bowled over by its effectiveness that they've
given it their own name, which translates roughly as "miracle."
Public health experts agree that artemisinen, when given with other drugs,
can cure malaria in three days. And they're meeting in New York today to
examine ways to make it the mainstay of a new assault on the mosquito-borne
disease, still the leading killer of African children.
Malaria parasites have become resistant to older drugs. But doctors say
that artemisinen-combination therapy, or ACT, is more expensive, and cost
has proven to be a major obstacle to widespread use. A complete three-day
course of therapy costs $1.50, at a minumum, vs. a dime per dose for
chloroqine or the widely used drug trade-named Fansidar.
Many African governments can only devote $5 or $6 per person per year to
public health.
"There's no denying that this will cost more, probably a lot more," says
Ron Waldman of Columbia University's Mailman School of Public Health, which
is sponsoring the conference with the World Health Organization, UNICEF and
Doctors without Borders. "But people now are spending a lot of money on
treatments that don't work."
The WHO pegs the annual cost of treating everyone in sub-Saharan Africa at
approximately $1 billion for drugs alone, says Allan Schapira, of WHO's
Roll Back Malaria program, begun in 1998.
Once a global scourge, malaria was endemic in the Southeast USA and killed
more American troops in the South Pacific during World War II than the
Japanese.
The WHO's global eradication effort, begun in the 1950s, wiped out malaria
in the USA by 1951 and in Europe by 1979. Doomed by surging drug resistance
and a global phase-out of the pesticide DDT, the campaign faltered.
Now malaria has come roaring back, especially in Africa, home to the
deadliest of the four malaria parasites, Plasmodium falciparum.
Research indicates that the number of cases reported in the last two
decades is four times that of the previous 20 years. The toll: 300 million
to 500 million each year, 90% of them in Africa, according to WHO. Many
victims are infants. The disease costs Africa's economy an estimated $12
billion.
Epidemics have surged, too, including one in Burundi three years ago that
affected half of the country's 6.5 million people and killed 13,000 of
them. An outbreak in Ethiopia last year caused some 15 million cases,
triple the usual number, unchecked by outdated drugs.
"The response to the epidemic was so ineffectual, you might not have
bothered," said Christa Hook of Doctors without Borders.
Those failures, and the likelihood that the WHO's Roll Back Malaria
campaign would fail to meet its goal of cutting cases in half by 2010,
prompted a group of angry doctors to accuse WHO, the Global Fund for AIDS,
Tuberculosis and Malaria and the U.S. Agency for International Development
of "medical malpractice," for failing to aggressively attack malaria with
effective drugs.
"Those of us in the scientific community know this shift has to happen, but
when it comes to get support from the world's donor community, what you get
is a great sucking sound," says Amir Attaran, of London's Royal Institute
of International Affairs, an author of a salvo in the January issue of the
British medical journal Lancet.
Attaran is especially critical of USAID for focusing more on
pesticide-coated bed nets than medicines, though the bed nets and DDT are
believed to be critical to any malaria-control program.
Anne Peterson, USAID's assistant administrator for Global Health, concedes
that the agency doesn't buy drugs directly and supply them to countries in
need. Rather, she says, it will provide funding, technical assistance and
prod manufacturers to increase production.
"Our business is to get global production from 20 million doses, half of
which go to Asia, to 100 million doses for Africa," she says.
Burundi, Zambia, Kenya, Sierra Leone and Zanzibar are shifting to ACT as
first-line treatment.
The best evidence that the new drugs work comes from South Africa's KwaZulu
Natal province, parts of which border the malaria belt in Mozambique. In
2001, doctors introduced Novartis's ACT therapy trade-named Coartem, as
part of an aggressive malaria control campaign that also relied on careful
use of DDT.
Malaria cases plummetted by about 77%, and deaths dropped by nearly 90%. By
killing the infectious form of the parasite in human blood, the drug also
reduced mosquito transmission from one person to another.
Each cure cost $11, compared with $146 for the ineffective drugs ? because
patients taking them needed more medical care, says author, Charlotte
Muheki, a health economist at the University of Cape Town.
Coartem is the only one of the ACTs now available that comes in a
fixed-dose form, but it is slightly more expensive than the other ACTs
available. Novartis does not profit from the sale of the drug.
The KwaZulu Natal experience revealed a challenge to successful use of the
new drugs ? making sure patients take all their medicine so parasites don't
become resistant to this therapy, too.
"Because this drug is like a wonder drug, you take the first dose and feel
brilliant," Muheki says. "You forget to take it for the rest of the day."
Posted on Fri, Apr. 30, 2004
Funds Hamper Those Who Need Malaria Drugs
BARBARA BORST
Associated Press
NEW YORK - Medicines to fight the rising malaria epidemic don't reach
millions who need them because the money and the international commitment
to supply the drugs are lacking, experts said at a conference here.
Although malaria kills more than a million people a year - most of them
African children - national and international policy makers show a "lack of
urgency and political will" to use new treatments in the face of drug
resistance, conference organizers said in a statement. Sponsors of the
two-day symposium, which ends Friday, were Columbia University, UNICEF, the
World Health Organization and the medical aid group Doctors Without Borders
(MSF).
New, highly effective combination therapies cost about $1 per treatment,
but that is about 10 times the price of their predecessors, and donations
haven't kept pace. Some experts say $2 billion or more will be needed for
drugs each year, but the two-year-old Global Fund to Fight AIDS,
Tuberculosis and Malaria has spent a total of $2.1 billion for all three
diseases, with 23 percent, or $491.4 million, going for malaria.
Donors need to double or triple their contributions to the Global Fund,
said Dr. Jean-Marie Kindermans of MSF, adding that he was "disappointed by
discussions with donors" during the conference.
With at least 300 million acute cases of malaria every year, experts also
cited concerns over long lead times to produce the newer drugs. MSF urged
using incentives for manufacturers to avert a shortage and consequent price
increases.
"One clear barrier that seems to be the most difficult to surmount is the
financial barrier," Dr. Ronald Waldman, deputy director of Columbia's
Center for Global Health, told journalists Thursday. "Those people in
charge of the money are spending it on other places, like Iraq."
Waldman said health budgets for developing countries remain constant even
as costs increase. It would be "a very bitter pill," he added, if
purchasing effective anti-malaria medicines cut into other care.
Resistance to two widely used malaria medications, chloroquine and
sulfadoxine-pyrimethamine, is on the rise; in some areas, it has reached 80
percent. Death rates are climbing, too, despite WHO's Roll Back Malaria
program, launched six years ago to cut deaths from malaria in half by 2010.
Combination drug therapies using artemisinin, derived from an Asian plant,
and synthetic compounds have proved highly effective against the malaria
parasite, which is transmitted by mosquitos.
WHO now recommends that all countries experiencing resistance to
conventional malaria medicines use combination therapies, preferably
including artemisinin derivatives.
Dr. Fatomata Nafo-Traore, Roll Back Malaria director, and other conference
organizers said an article in the British medical journal The Lancet in
January helped spur new tactics. The authors accused WHO, the Global Fund
and others of "medical malpractice in malaria treatment" for continuing to
use older medicines in areas of high drug resistance.
"Thankfully, WHO has (since) been much more aggressive about doing the
right thing," Amir Attaran, lead author of the article, told The Associated
Press by telephone. "Media pressure has been instrumental where science has
not been."
Other organizations have not improved their practices, he said, singling
out the U.S. Agency for International Development as "the most perfidious"
and accusing it of pressuring African governments not to seek funds for
ACTs.
It could cost $2 billion to $3 billion a year to get ACTs to Africa, but
that would be "a huge bargain" because sickness and death from malaria
deepen poverty and prevent development, said Attaran, of the Royal
Institute of International Affairs in London.
Dr. Anne Peterson of USAID defended the agency, saying it is "actively
promoting the transition to ACTs, but there isn't enough of the drugs for
everybody." It spends its funds on preventing malaria infections and
providing technical advice to African governments, rather than buying
drugs, she told The AP by telephone.
USAID chief Andrew Natsios has said the agency sees ACTs as "the most
effective malaria treatment" and will spend $83 million on malaria this
year and give $398 million to the Global Fund.
Nafo-Traore said the number of countries using or planning to use ACTs has
climbed from half a dozen last year to about 30 now. Anti-malaria efforts
include preventive measures such as mosquito nets and insecticides, she
added.
As funding and the ability to supply the drugs improve, WHO expects demand
for ACTs to rise to 200 million treatments by the end of 2005 and to 1
billion a year thereafter.
"The next step is how to respond to this increase in demand," Nafo-Traore
said.
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