Caroline Lynch & Jim TullochJune 2014

Synthesis of current evidence on the multiple causes of malaria drug resistance

Overview 1. Why do drugs stop working?2. What actions are potentially accelerating antimalarial

resistance?3. Update on artemisinin resistance.4. Policy options.

Accidents during reproduction

Mutations

Helps parasiteHinders parasite No effect

Susceptible parasite

Parasite with mutations

1. Why do drugs stop working?

Treatment

Drug selection for resistant parasites

• If parasites have a mutation which protects them from treatment they will survive.

• Susceptible parasites are eliminated - the drug has ‘selected’ resistant parasites.

• Resistant parasites will produce gametocytes which can be transmitted to mosquito.

Susceptible and resistant parasites

Imagine a malaria-endemic village

Drug pressure

Antimalarial treatment

Susceptible parasite

Resistant parasite

What could contribute to drug pressure?

A high proportion of the population with variable amounts of antimalarials in their bloodstream – how?

o High malaria transmissiono Too much treatment (overtreatment) o Too little treatment (undertreatment/ partial

treatment).

Why too much treatment?

Why too little treatment?Supply side

2. What actions are potentially accelerating antimalarial resistance?Supply side • Treatment without

diagnosisDemand side

• Patients seek treatment without diagnosis

• Availability of monotherapy (direct selection) and substandard antimalarials

• Partial treatment provided to patients

• Patients take partial treatment

Demand side

Demographic factorsMigration Chloroquine resistance

Sulfadoxine-Pyrimethamine resistance

Previously resistance emerged in GMS and spread.

• High mobility in GMS• Increased ties with Africa• High potential for spread

of AR

3. Update on artemisinin resistance • Artemisinin resistance has been detected in all GMS

countries.

• GPARC and regional containment strategies in place.• In 2013;

o Emergency Response to Artemisinin Resistance (ERAR).o Funds for artemisinin resistance containment.o Molecular marker (Kelch 13) identified.

4. Policy options

• Ban monotherapy and eliminate substandard antimalarialso Part of broader recommendation to improve

regulatory capacity

• Facilitate cross-border surveillance & multisectoral collaboration.

• Establish agile and aggressive field team to support ERAR.

• Ensure immediate implementation of primaquine policy.

• Create flexible fund for specific, answerable questions around interim antimalarial dosing and treatmento Part of broader recommendation on funding for

Operational Research

Develop strong regional mechanisms for rapid response

• Track and respond to artemisinin resistance

Track : Immediately begin monitoring 1-2 artemisinin resistance indicators updated monthly by secretariat.

Respond: Where countries are not on track – taskforce identify bottlenecks and provide immediate support to countries to find solutions.

Ensure accountability & transparency

• Advocate to the DG/WHO for AR to be reviewed - Public Health Emergency of International Health.

All avenues of advocacy

• Continue advocacy at regional level to ensure political support for technical frameworks for artemisinin resistance elimination

o Part of broader recommendation for ongoing advocacy in support of malaria elimination

High level collective advocacy

“A regional public health disaster which could have

severe global consequences” (WHO, 2014)

There is a window of opportunity if we act now