Global Antimalarial Drug Resistance Management and Containment Strategies Dr Kamini Mendis WHO...

Global Antimalarial Drug Resistance Management and Containment Strategies

Global Antimalarial Drug Resistance Management and Containment Strategies

Dr Kamini Mendis WHO Global Malaria ProgrammeDr Kamini Mendis WHO Global Malaria Programme

Challenges & responses for malaria in Asia

15th RBM Partnership Board Meeting

New Delhi, India, 10th November 2008

Challenges & responses for malaria in Asia

15th RBM Partnership Board Meeting

New Delhi, India, 10th November 2008

RBM Board Meeting, New Delhi 10-11 November 2008 2 |GLOBAL

MALARIA PROGRAMME

The situation todayThe situation today

P.falciparum has developed a tolerance to artemisinins at the Cambodia-Thailand border – which will progress to resistance if not contained.

Most of the antimalarials of the past have been lost to resistance

Today the world is entirely dependent on artemisinins for the treatment of falciparum malaria


MALARIA PROGRAMME

75 countries have adopted ACTs

Countries which need ACT policy

Countries which adopted ACT

Countries Deploying ACTs

Countries with ACTs at Community level

Update: May Update: May 20082008


MALARIA PROGRAMME

The situation todayThe situation today

P.falciparum has developed a tolerance to artemisinins at the Cambodia-Thailand border – which will progress to resistance if not contained.

Almost all antimalarials of the past have been lost to resistance

Today the world is entirely dependent on artemisinins for the treatment of falciparum malaria

No replacements for artemisinins in the late pipeline of development


MALARIA PROGRAMME

Pipeline of new antimalarial medicines up to 2010Pipeline of new antimalarial medicines up to 2010

+

AS-MQ

2010200920082007

co-blistered products

AS-AQCD-AS (CDA)

DHA-PPQ

PaediatricCoartem™

Pyronaridine-ASPyramax™

Art-Naphthoquine

Art-PPQ

<2006

Fixed-dose combinations

artemether-lumefantrine

X

Alternatives Alternatives to artemisininto artemisinin

? ?


MALARIA PROGRAMME

How best can we delay the onset and spread of drug resistance?

How best can we delay the onset and spread of drug resistance?

Early detection of tolerance / resistance to artemisinins

Routinely monitor therapeutic efficacy of ACTs– In vivo studies on ACTs and artesunate

WHO supported routine surveillance of drug resistance– Standardized methodologies, tools and technical assistance– To countries and regional and sub-regional networks


MALARIA PROGRAMME

RAVREDA

Mekong

HANMAT

Regional and sub-regional networks on monitoring drug efficacy

Regional and sub-regional networks on monitoring drug efficacy

TET is important specially where SP and

AQ are partner medicines


MALARIA PROGRAMME

Strategies to prolong the life of ArtemisininsStrategies to prolong the life of Artemisinins

Use of combination medicines – and prevent the use of

AS by itself

– Withdraw oral artemisinin monotherapeis from market


MALARIA PROGRAMME

January 2006


MALARIA PROGRAMME

Steps to implement WHO recommendationsSteps to implement WHO recommendations

1. 19 January 2006 – WHO Press Release 2. Monitoring marketing practices and position of NDRA 3. Dissemination of WHO position via WHO Offices, WHO staff briefings,

inter-country and regional meetings with MOH officials 4. 19 April 2006 – WHO technical briefing on malaria guidelines and

artemisinin monotherapies5. Alignment of funding and procurement agencies

6. 23 May 2007 - WHA Resolution 60.187. 24 August 2007 – WHO informal consultation with

manufacturers of artemisinin-based antimalarials 8. WHO country meetings with pharmaceutical companies

(India, China, Pakistan, Viet Nam)9. Monitoring system on http://malaria.who.int/


MALARIA PROGRAMME

0

5

10

15

20

25

30

2006 2007 2008

Identified in

Not yet contacted

No intention disclosed

Intention to comply

Withdrawn monotherapies

Number of companies

Manufacturers of oral artemisinin monotherapies: 12/67 (18%) withdrew their products

22/67 (33%) intend to comply with WHO ban

SubstandardMedicines ?


MALARIA PROGRAMME

National Drug Regulatory Authorities National Drug Regulatory Authorities

0

10

20

30

40

50

60

70

Janu

ary

April

July

Octo

ber

Janu

ary

April

July

Octo

ber

Janu

ary

April

Risk of developing resistanceRisk of developing resistance

20062006 20072007 20082008

No. countries marketing oral artemisinin monotherapiesNo. countries marketing oral artemisinin monotherapiesNo. countries marketing oral artemisinin monotherapiesNo. countries marketing oral artemisinin monotherapies


MALARIA PROGRAMME


Use of combination medicines – discontinue the use of

AS alone



MALARIA PROGRAMME

Access to medicinesAccess to medicines

0

20

40

60

80

100

Ch

ild

ren

<5

yr t

reat

ed w

ith

an

tim

alar

ial

(%)

Any antimalarial

ACTtarget

Availability of any antimalarial medicine and ACTs to children with fever, 2006–2007 Availability of any antimalarial medicine and ACTs to children with fever, 2006–2007 (DHS, MICS, MIS surveys)(DHS, MICS, MIS surveys)


MALARIA PROGRAMME


– Improve access to ACTs & parasitological confirmation of

diagnosis

Use of combination medicines – discontinue the use of

AS alone


– Reducing transmission rates

• To lower the risk of spreading mutant resistant parasites


MALARIA PROGRAMME

Main challengesMain challenges

Weak surveillance systems to monitor therapeutic efficacy of ACTs in

countries

Companies non responsive to request to withdraw marketting of

monotherapies

Poorly regulated pharmaceutical market in endemic countries

Limited access to ACT: i) slow roll-out of ACTs in the public sector and ii)

limited penetration of ACTs in the private sector

Manufacturing of sub-standard products exploiting "niche market" left open

by companies complying with WHO recommendations

Need for multiple sources of information for monitoring


MALARIA PROGRAMME

To avoid artemisinin resistance….To avoid artemisinin resistance….

Correct policies in place

Support implementation of strategies including with necessary funding

Effective Government regulation

Co-operation from the pharmaceutical sector

Supportive action by all partners

Global Antimalarial Drug Resistance Management and Containment Strategies Dr Kamini Mendis WHO...

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