Academic journal article Bulletin of the World Health Organization

Influence of Blister Packaging on the Efficacy of Artesunate + Mefloquine over Artesunate Alone in Community-Based Treatment of Non-Severe Falciparum Malaria in Myanmar

Academic journal article Bulletin of the World Health Organization

Influence of Blister Packaging on the Efficacy of Artesunate + Mefloquine over Artesunate Alone in Community-Based Treatment of Non-Severe Falciparum Malaria in Myanmar

Article excerpt

Introduction

Artemisinin derivatives (AD, i.e. artemether injections, artesunate injections, and artesunate tablets) have been shown to be effective in the treatment of severe Plasmodium falciparum malaria in southeast Asia. Unfortunately, these compounds have a high recrudescence rate (up to 25-40%) even when used for the recommended 5 days to treat uncomplicated malaria cases. Although these compounds have recently become widely available in Myanmar, prescribing practices of health workers and the compliance of patients with uncomplicated malaria have not been studied. This information is needed to develop strategies for the control and rational use of these drugs in order to preserve their effectiveness in treating severe and complicated falciparum cases, especially in areas of multidrug-resistant malaria.

In 1994 a hospital-based study in Myanmar showed that a 7-day treatment using oral dihydroartemisinin (Cotecxin) was 100% efficacious against nonsevere malaria (1); there was no recrudescence in any of the 30 patients who were followed up for 28 days. As for compliance, another study of 20 outpatients with non-severe malaria showed that 25% discontinued when the symptoms cleared and did not finish the full course (2, 3). It was considered unreasonable to expect 7 days of compliance, and when 3 and 5-day regimens were examined the cure rates fell to 84% and 89.5%, respectively. Resistance to mefloquine, the third-line drug in most of Myanmar, has been documented in many areas of South-East Asia. Along the Thai-Myanmar border, for example, 41.7% of patients have been reported to be resistant to mefloquine in vivo (4). However, there is no reported resistance to the combination artesunate and mefloquine (5-7). We therefore considered promoting the addition of mefloquine to artesunate regimens in order to decrease the probability of recrudescence and retard the spread of mefloquine resistance (8-11).

The following studies were conducted in sequence:

(1.) Use of artemisinins: a retrospective study to characterize current use and conditions for the use of artemisinin derivatives.

(2.) Subsidized mefloquine intervention: to promote the use of a combined artesunate + mefloquine regimen for uncomplicated malaria by educating health care providers and subsidizing the cost of mefloquine to patients.

(3.) Packaging intervention: to improve the compliance with artesunate + mefloquine by packaging and distributing them together in blister packs.

Use of artemisinins

Methods

This retrospective study to evaluate current use of artemisinin compounds in Myanmar was conducted in the following areas:

-- two townships with a high prevalence of malaria (Pyin Oo Lwin and Myit Kyi Na);

-- one township where drug resistance is common (Mawlamine);

-- one township in central Myanmar (Thayarwady);

-- one township with a low prevalence of malaria (Maubin); and

-- one township with a large migrant population close to jade mines (Moekaung).

Questionnaires on the use of artemisinins were prepared for interviews with the following individuals: hospital doctors and general practitioners in the townships; nurses, health assistants and midwives; auxiliary midwives and voluntary health workers; drug store owners in the townships; and former hospital patients who had experienced severe and complicated malaria. Meetings with the hospital doctors and general practitioners were held through the various branches of the Myanmar Medical Association, at which the questionnaires were distributed and filled in by the doctors. A similar exercise was repeated with the nurses and paramedical workers in the townships. A coverage of approximately 80% of all doctors and nurses from the specified townships was obtained.

Results

A total of 129 doctors were interviewed. Artemisinin compounds were prescribed as first-line treatment by 9. …

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