- Email: [email protected]
Importance of protection of antimalarial combination therapies
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1754
waters providing breeding sites for large numbers of mosquitoes. Cases of malaria in Pakistan have also been imported in the past few decades because of the influx of Afghan refugees. In the many camps that the Afghan refugees occupied in Pakistan, 150 000 cases of malaria were diagnosed and treated each year, about 30% of which were due to Plasmodium falciparum.3 The national policy is to prescribe chloroquine as the first-line antimalarial drug. However, chloroquine resistance has been noted throughout the country, which is now seen to be the main reason for an increase in the prevalence of falciparum malaria in Pakistan. According to surveys, RI resistance (whereby asexual parasitaemia reduces to <25% of pretreatment levels in 48 h, but reappears) has a frequency of 30–84%, RII resistance (25–75% reduction in asexual parasitaemia in 48 h, without complete clearance in 7 days) is relatively rare, and RIII resistance (<25% reduction in asexual parasitaemia or increase in parasitaemia after 48 h) has not yet been noted. Such findings have raised questions about the effectiveness of chloroquine as the first-line treatment for falciparum malaria.4 Rapid development of resistance to sulfadoxine-pyrimethamine has also been seen in Pakistan. Results of a small-scale study put sulfadoxinepyrimethamine resistance at around 37% among the locals.5 Although the efficacy of sulfadoxine-pyrimethamine in the Afghan refugee camps is still high,3 the appearance and upsurge of resistance in Pakistan is an issue of indubitable concern. Trials such as the one by Alloueche and colleagues are badly needed in Pakistan. Collaboration between public sectors, non-governmental organisations, and pharmaceutical industries would be beneficial in monitoring drug resistance where the infrastructure for such surveillance is lacking. Future endeavours in this
regard would be helpful for health policy makers in the planning, implementation, and monitoring of treatment strategies in countries where resources are scarce.
*Nudrat Noor, Ahmed Rattani [email protected] Aga Khan University, PO Box 3500, Stadium Road, Karachi 74800, Pakistan 1
2
3
4
5
Alloueche A, Bailey W, Barton S, et al. Comparison of proguanil-dapsone with sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in young African children: doubleblind randomised controlled trial. Lancet 2004; 363: 1843–48. Integrated Regional Information Networks (IRIN). Pakistan: outbreak of deadly form of malaria worries medical association. IRINNews.org Feb 23, 2004. http://www. irinnews.org (accessed June 25, 2004). Rowland M, Nosten F. Malaria epidemiology and control in refugee camps and complex emergencies. Ann Trop Med Parasitol 2001; 95: 741–54. Shah I, Rowland M, Mehmood P, et al. Chloroquine resistance in Pakistan and the upsurge of falciparum malaria in Pakistani and Afghan refugee populations. Ann Trop Med Parasitol 1997; 91: 591–602. Sanaullah MAB. Falciparum malaria: a review of 120 cases. J Coll Physicians Surg Pak 2001; 11: 300–03.
Importance of protection of antimalarial combination therapies Peter Kremsner and Sanjeev Krishna (July 17, p 285)1 state that new antimalarial combination therapies should be used alongside other malaria control measures. Failure to grasp this essential and understated point could cause premature loss of deployed therapies to onset of resistance. In the Review, Thailand was mentioned for its successful implementation of artemisinin-based combination therapy (ACT). Indeed, for 10 years, a 2-day regimen of artesunate-mefloquine (not 3-day) has been used in selected areas under the national malaria control programme. This shorter course results in greater adherence to prescribed therapy among outpatients. Thailand regulates
both artesunate and mefloquine, which are not legally available without a prescription. The nationwide system of malaria clinics, which do not prescribe ACT before microscopic confirmation of malaria, has more than 80% coverage of patients. Moreover, insecticide spraying and other control measures are routinely practised. This broad and disciplined application of resources is key to the sustainability of ACT effectiveness in Thailand.2 ACT has been deployed in nations without many of the advantages available to Thailand. The combination proves an irresistible means of providing immediate relief to individual patients and of reducing malaria morbidity. However, ACT often arrives before operational issues necessary for its implementation can be fulfilled.3 Because of the absence of companion malaria control measures and poor health-care infrastructure, some nations are not ready to protect ACT from the misuse that places it at risk as an effective treatment. Regulations to prevent its indiscriminate use for selftreatment and to protect patients from counterfeit drugs also constitute a tremendous challenge. Attempts to improve operational measures depend on enormous efforts and expenses, but guarantee no success. In Cambodia, blister packs, containing artesunate and mefloquine tablets for a 3-day treatment course, have been used to try to improve compliance in both public and private sectors since 2000. Nonetheless, there is an indication that this measure only slightly improves patients’ drug use behaviours, and subtherapeutic use remains common. Mefloquine-resistant strains of Plasmodium falciparum have been widespread at the Cambodian-Thai border for nearly two decades, raising the possibility that the efficacy of artesunatemefloquine combination used in Cambodia could be lost; its efficacy is therefore being actively monitored. Loss of efficacy could easily occur in settings where ACT use cannot be fully disciplined, and other measures aimed at www.thelancet.com Vol 364 November 13, 2004
simultaneously diminishing risk of infection are insufficient, for example, malaria prevention through impregnated bed nets. Deployment of ACT effectively depends on more than drug availability.
Socheat Duong, Pharath Lim, Thierry Fandeur, Reiko Tsuyuoka, *Chansuda Wongsrichanalai [email protected] National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia (SD); Pasteur Institute, Phnom Penh, Cambodia (PL, TF); World Health Organization, Phnom Penh, Cambodia (RT); and *US Naval Medical Research Unit No 2 (NAMRU-2), Jakarta, Indonesia (CW) 1
2
3
Kremsner PG, Krishna S. Antimalarial combinations. Lancet 2004; 364: 285–94. Wongsrichanalai C, Prajakwong S, Meshnick SR, Shanks GD, Thimasarn K. Mefloquine: its 20 years in the Thai malaria control program. Southeast Asian J Trop Med Public Health 2004; 35: 300–08. WHO. The use of antimalarial drugs: report of a WHO informal consultation, Nov 13–17, 2000. Geneva: World Health Organization, 2001. http://whqlibdoc.who.int/hq/2001/ WHO_CDS_RBM_2001.33.pdf.
Obstacles to health information for all Success in achieving health information for all by 2015 is doubtful. In developing countries, where the priorities are often survival and improved environmental conditions, computers and the internet are still considered innovations. The Public Health article by Fiona Godlee and colleagues (July 17, p 295)1 is information-centred and not client-centred. Some difficulties are underestimated. First, diffusion of innovation has always been a challenge, and the many good ideas that have not succeeded indicate how difficult it is to move people to change.2 For example, the popularisation of bottle feeding among mothers in developing countries contributed directly to widespread infant diarrhoea,2 yet replacement of breast feeding with prepared infant formulas was an excellent objective that was unsuccessful. Can those new technologies for www.thelancet.com Vol 364 November 13, 2004
communication and information help to disseminate positive messages and implement better health-care practice? We should consider the recommendations made by Berwick3 for promoting innovations in health care that explore three areas of influence: perception of the innovation, characteristics of the individual who might adopt the change, and contextual and managerial factors within organisations. Second, the language issue is not addressed sufficiently. Even if the world could communicate through one language, issues related to history, culture, and social behaviour are important. Godlee and colleagues mention the Latin American initiatives, but surely there also exist other languages and cultures in this communicating world—eg, Asian languages, German, French, etc. Third, the quality of information is well discussed. We have little data about the quality of information on the internet, and cannot conclude that it is poor. However, the flood of information through e-documents does not imply better quality. We already have data4 that suggest the quality of references is decreasing with increasing use of the internet. Is all information on the internet of poor quality? Finally, information without education in clinical epidemiology could be harmful. Godlee and colleagues present numerous initiatives for teaching critical appraisal. After the 1978 Alma Ata Declaration (Health for all by the year 2000), the International Clinical Epidemiology Network (INCLEN) was established in 1982.5 The network is based on local organisations in Asia Pacific, Latin America, India, and Africa that adapt the subject matter to be taught to local cultures. After 20 years, insufficient progress has been made, and funding is a key factor for success. Initiatives of foreign counterparts, such as the French Réseau d’Epidémiologie Clinique International Francophone (RECIF) network (http:// recif.univ-lyon1.fr/) should be encour-
aged. Such a model, with local adaptation to different cultures, should be used to disseminate information.
*Hervé Maisonneuve, Yves Matillon, Dominique Bertrand [email protected] *Department of Public Health, Paris 7 University, 75010 Paris, France (HM, DB); and Department of Public Health, Claude Bernard University, Lyon, France (YM) 1
2 3 4
5
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Godlee F, Pakenham-Walsh N, Ncayiyana D, Cohen B, Packer A. Can we achieve health information for all by 2015? Lancet 2004; 364: 295–300. Rogers EM. Diffusion of innovations, 4th edn. New York: Free Press, 1995. Berwick D. Disseminating innovations in health care. JAMA 2003; 289: 1969–75. Johnson KR, Hester EJ, Schilling LM, Delavalle RP. Addressing internet reference loss. Lancet 2004; 363: 660–61. Halstead SB, Tugwell P, Bennett K. The international clinical epidemiology network (INCLEN): a progress report. J Clin Epidemiol 1991; 44: 579–84.
Fiona Godlee and colleagues1 note that most health professionals in the developing world are no better informed now than they were 10 years ago, a sentiment that Christopher Bailey and Tikki Pang echo in their accompanying Comment.2 They cannot be. In Latin America, for example, language and cost, plus deficient and delayed international mail systems represent major barriers. Godlee and colleagues note that “most health workers in developing countries will not or cannot pay for information themselves and that as much information as possible should therefore be free”. Traditionally, the only free information provided in the native language (as it should be) is distributed by the pharmaceutical industry and available to only a quarter of the doctors in any given country and to those concentrated in cities. Furthermore, such education is obviously limited to the areas in which the provider is interested—namely, specific diseases and pharmaceutical products. Local and regional information services should certainly be developed, as suggested in the Public Health article. However, these should be in the native 1755
Still Pictures
Correspondence
Correspondence
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
1754
waters providing breeding sites for large numbers of mosquitoes. Cases of malaria in Pakistan have also been imported in the past few decades because of the influx of Afghan refugees. In the many camps that the Afghan refugees occupied in Pakistan, 150 000 cases of malaria were diagnosed and treated each year, about 30% of which were due to Plasmodium falciparum.3 The national policy is to prescribe chloroquine as the first-line antimalarial drug. However, chloroquine resistance has been noted throughout the country, which is now seen to be the main reason for an increase in the prevalence of falciparum malaria in Pakistan. According to surveys, RI resistance (whereby asexual parasitaemia reduces to <25% of pretreatment levels in 48 h, but reappears) has a frequency of 30–84%, RII resistance (25–75% reduction in asexual parasitaemia in 48 h, without complete clearance in 7 days) is relatively rare, and RIII resistance (<25% reduction in asexual parasitaemia or increase in parasitaemia after 48 h) has not yet been noted. Such findings have raised questions about the effectiveness of chloroquine as the first-line treatment for falciparum malaria.4 Rapid development of resistance to sulfadoxine-pyrimethamine has also been seen in Pakistan. Results of a small-scale study put sulfadoxinepyrimethamine resistance at around 37% among the locals.5 Although the efficacy of sulfadoxine-pyrimethamine in the Afghan refugee camps is still high,3 the appearance and upsurge of resistance in Pakistan is an issue of indubitable concern. Trials such as the one by Alloueche and colleagues are badly needed in Pakistan. Collaboration between public sectors, non-governmental organisations, and pharmaceutical industries would be beneficial in monitoring drug resistance where the infrastructure for such surveillance is lacking. Future endeavours in this
regard would be helpful for health policy makers in the planning, implementation, and monitoring of treatment strategies in countries where resources are scarce.
*Nudrat Noor, Ahmed Rattani [email protected] Aga Khan University, PO Box 3500, Stadium Road, Karachi 74800, Pakistan 1
2
3
4
5
Alloueche A, Bailey W, Barton S, et al. Comparison of proguanil-dapsone with sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in young African children: doubleblind randomised controlled trial. Lancet 2004; 363: 1843–48. Integrated Regional Information Networks (IRIN). Pakistan: outbreak of deadly form of malaria worries medical association. IRINNews.org Feb 23, 2004. http://www. irinnews.org (accessed June 25, 2004). Rowland M, Nosten F. Malaria epidemiology and control in refugee camps and complex emergencies. Ann Trop Med Parasitol 2001; 95: 741–54. Shah I, Rowland M, Mehmood P, et al. Chloroquine resistance in Pakistan and the upsurge of falciparum malaria in Pakistani and Afghan refugee populations. Ann Trop Med Parasitol 1997; 91: 591–602. Sanaullah MAB. Falciparum malaria: a review of 120 cases. J Coll Physicians Surg Pak 2001; 11: 300–03.
Importance of protection of antimalarial combination therapies Peter Kremsner and Sanjeev Krishna (July 17, p 285)1 state that new antimalarial combination therapies should be used alongside other malaria control measures. Failure to grasp this essential and understated point could cause premature loss of deployed therapies to onset of resistance. In the Review, Thailand was mentioned for its successful implementation of artemisinin-based combination therapy (ACT). Indeed, for 10 years, a 2-day regimen of artesunate-mefloquine (not 3-day) has been used in selected areas under the national malaria control programme. This shorter course results in greater adherence to prescribed therapy among outpatients. Thailand regulates
both artesunate and mefloquine, which are not legally available without a prescription. The nationwide system of malaria clinics, which do not prescribe ACT before microscopic confirmation of malaria, has more than 80% coverage of patients. Moreover, insecticide spraying and other control measures are routinely practised. This broad and disciplined application of resources is key to the sustainability of ACT effectiveness in Thailand.2 ACT has been deployed in nations without many of the advantages available to Thailand. The combination proves an irresistible means of providing immediate relief to individual patients and of reducing malaria morbidity. However, ACT often arrives before operational issues necessary for its implementation can be fulfilled.3 Because of the absence of companion malaria control measures and poor health-care infrastructure, some nations are not ready to protect ACT from the misuse that places it at risk as an effective treatment. Regulations to prevent its indiscriminate use for selftreatment and to protect patients from counterfeit drugs also constitute a tremendous challenge. Attempts to improve operational measures depend on enormous efforts and expenses, but guarantee no success. In Cambodia, blister packs, containing artesunate and mefloquine tablets for a 3-day treatment course, have been used to try to improve compliance in both public and private sectors since 2000. Nonetheless, there is an indication that this measure only slightly improves patients’ drug use behaviours, and subtherapeutic use remains common. Mefloquine-resistant strains of Plasmodium falciparum have been widespread at the Cambodian-Thai border for nearly two decades, raising the possibility that the efficacy of artesunatemefloquine combination used in Cambodia could be lost; its efficacy is therefore being actively monitored. Loss of efficacy could easily occur in settings where ACT use cannot be fully disciplined, and other measures aimed at www.thelancet.com Vol 364 November 13, 2004
simultaneously diminishing risk of infection are insufficient, for example, malaria prevention through impregnated bed nets. Deployment of ACT effectively depends on more than drug availability.
Socheat Duong, Pharath Lim, Thierry Fandeur, Reiko Tsuyuoka, *Chansuda Wongsrichanalai [email protected] National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia (SD); Pasteur Institute, Phnom Penh, Cambodia (PL, TF); World Health Organization, Phnom Penh, Cambodia (RT); and *US Naval Medical Research Unit No 2 (NAMRU-2), Jakarta, Indonesia (CW) 1
2
3
Kremsner PG, Krishna S. Antimalarial combinations. Lancet 2004; 364: 285–94. Wongsrichanalai C, Prajakwong S, Meshnick SR, Shanks GD, Thimasarn K. Mefloquine: its 20 years in the Thai malaria control program. Southeast Asian J Trop Med Public Health 2004; 35: 300–08. WHO. The use of antimalarial drugs: report of a WHO informal consultation, Nov 13–17, 2000. Geneva: World Health Organization, 2001. http://whqlibdoc.who.int/hq/2001/ WHO_CDS_RBM_2001.33.pdf.
Obstacles to health information for all Success in achieving health information for all by 2015 is doubtful. In developing countries, where the priorities are often survival and improved environmental conditions, computers and the internet are still considered innovations. The Public Health article by Fiona Godlee and colleagues (July 17, p 295)1 is information-centred and not client-centred. Some difficulties are underestimated. First, diffusion of innovation has always been a challenge, and the many good ideas that have not succeeded indicate how difficult it is to move people to change.2 For example, the popularisation of bottle feeding among mothers in developing countries contributed directly to widespread infant diarrhoea,2 yet replacement of breast feeding with prepared infant formulas was an excellent objective that was unsuccessful. Can those new technologies for www.thelancet.com Vol 364 November 13, 2004
communication and information help to disseminate positive messages and implement better health-care practice? We should consider the recommendations made by Berwick3 for promoting innovations in health care that explore three areas of influence: perception of the innovation, characteristics of the individual who might adopt the change, and contextual and managerial factors within organisations. Second, the language issue is not addressed sufficiently. Even if the world could communicate through one language, issues related to history, culture, and social behaviour are important. Godlee and colleagues mention the Latin American initiatives, but surely there also exist other languages and cultures in this communicating world—eg, Asian languages, German, French, etc. Third, the quality of information is well discussed. We have little data about the quality of information on the internet, and cannot conclude that it is poor. However, the flood of information through e-documents does not imply better quality. We already have data4 that suggest the quality of references is decreasing with increasing use of the internet. Is all information on the internet of poor quality? Finally, information without education in clinical epidemiology could be harmful. Godlee and colleagues present numerous initiatives for teaching critical appraisal. After the 1978 Alma Ata Declaration (Health for all by the year 2000), the International Clinical Epidemiology Network (INCLEN) was established in 1982.5 The network is based on local organisations in Asia Pacific, Latin America, India, and Africa that adapt the subject matter to be taught to local cultures. After 20 years, insufficient progress has been made, and funding is a key factor for success. Initiatives of foreign counterparts, such as the French Réseau d’Epidémiologie Clinique International Francophone (RECIF) network (http:// recif.univ-lyon1.fr/) should be encour-
aged. Such a model, with local adaptation to different cultures, should be used to disseminate information.
*Hervé Maisonneuve, Yves Matillon, Dominique Bertrand [email protected] *Department of Public Health, Paris 7 University, 75010 Paris, France (HM, DB); and Department of Public Health, Claude Bernard University, Lyon, France (YM) 1
2 3 4
5
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Godlee F, Pakenham-Walsh N, Ncayiyana D, Cohen B, Packer A. Can we achieve health information for all by 2015? Lancet 2004; 364: 295–300. Rogers EM. Diffusion of innovations, 4th edn. New York: Free Press, 1995. Berwick D. Disseminating innovations in health care. JAMA 2003; 289: 1969–75. Johnson KR, Hester EJ, Schilling LM, Delavalle RP. Addressing internet reference loss. Lancet 2004; 363: 660–61. Halstead SB, Tugwell P, Bennett K. The international clinical epidemiology network (INCLEN): a progress report. J Clin Epidemiol 1991; 44: 579–84.
Fiona Godlee and colleagues1 note that most health professionals in the developing world are no better informed now than they were 10 years ago, a sentiment that Christopher Bailey and Tikki Pang echo in their accompanying Comment.2 They cannot be. In Latin America, for example, language and cost, plus deficient and delayed international mail systems represent major barriers. Godlee and colleagues note that “most health workers in developing countries will not or cannot pay for information themselves and that as much information as possible should therefore be free”. Traditionally, the only free information provided in the native language (as it should be) is distributed by the pharmaceutical industry and available to only a quarter of the doctors in any given country and to those concentrated in cities. Furthermore, such education is obviously limited to the areas in which the provider is interested—namely, specific diseases and pharmaceutical products. Local and regional information services should certainly be developed, as suggested in the Public Health article. However, these should be in the native 1755
Still Pictures
Correspondence