We must avert the looming malaria threat!

Francis Kokutse, in Accra, Ghana  

Francis Kokutse is a journalist based in Accra and writes for Associated Press (AP), University World News, as well as Science and Development.Net. He was a Staff Writer of African Concord and Africa Economic Digest in London, UK. 

There is trouble brewing with malaria as there are signs that resistance to some drugs is causing young African children to suffer from serious infections. For this reason,  health policy makers on the continent  must be on their toes to avert any possible crisis with malaria, the American Society of Tropical Medicine and Hygiene (ASTMH) has cautioned following the publication of the  study on Malaria Drugs Resistance Behind Deaths In Children.

The World Health Organisation (WHO) says some  people are more vulnerable to malaria than others, stating that partial immunity to malaria can be developed over years of exposure.  The WHO said since young children have not had the opportunity to build up this partial immunity, they are particularly at risk and make up the majority of fatal cases of malaria in the African region.

It said, as well as having a significant human cost, the effects of malaria extend far beyond direct measures of morbidity and mortality. Malaria can reduce school attendance, productivity at work, and there is evidence that the disease can also impair intellectual development. The economic costs are also significant. 

“Between 1965 and 1990, countries in which a large proportion of the population lived in regions with malaria experienced an average growth in per-capita GDP of 0.4% per year, whereas average growth in other countries was 2.3% per year,” the WHO said.

In a statement to prove its point, the ASTMH said a new study from Uganda has provided  the first evidence to date that resistance to a lifesaving malaria drug may be emerging in the group of patients that accounts for most of the world’s malaria deaths.

The ASTMH, founded in 1903, is the largest international scientific organisation of experts dedicated to reducing the worldwide burden of tropical infectious diseases, and improving global health. It accomplishes this through generating and sharing scientific evidence, informing health policies and practices, fostering career development, recognising excellence, and advocating for investment in tropical medicine/global health research.

Referring to the study published in the Journal of the American Medical Association (JAMA), ASTMH said, it  has documented partial resistance to the malaria drug, artemisinin, in 11 of 100 children, ages 6 months to 12 years, who were being treated for “complicated” malaria, that is, malaria with signs of severe disease caused by the malaria parasite, Plasmodium falciparum.

 Also, 10 patients who were thought to have been cured suffered a repeat malaria attack within 28 days from the same strain of malaria that caused the original infection, suggesting that the initial treatment did not fully kill the infecting parasites.

A co-author of the study, Chandy John, director of the Indiana University School of Medicine’s  Ryan White Center for Infectious Diseases and Global Health, said  “this is the first study from Africa showing that children with malaria and clear signs of severe disease are experiencing at least partial resistance to artemisinin.”

John co-authored the study with colleagues, Ruth Namazzi, and Robert Opoka from Makerere University in Kampala in Uganda, Ryan Henrici from University of Pennsylvania, and Colin Sutherland from London School of Hygiene & Tropical Medicine.

“It’s also the first study showing a high rate of African children with severe malaria experiencing a subsequent malaria episode with the same strain within 28 days of standard treatment with artesunate, a derivative of artemisinin, and an artemisinin combination therapy (ACT),” John, who is a former president of the ASTMH, said.

In their statement, the ASTMH said the  arrival of artemisinin therapies some 20 years ago was a major advance in the global fight against malaria due to their power to rapidly cure infections — and because malaria parasites had developed resistance to other drugs.

“In 2008, there were reports from Cambodia noting partial resistance to artemisinin. By 2013 there was evidence that in some patients, the drug was completely failing. In the last few years, there has been increasing evidence that artemisinin resistance has now spread from that region into East Africa,” the statement said.

For this reason, they said, the prospect of artemisinin losing its efficacy is particularly alarming for Africa and especially, for African children. The region accounts for 95 percent of the 608,000 people who die from malaria each year and a large majority of malaria deaths in Africa are children under five. 

The ASTMH said, while all of the children in the study eventually recovered, 10 of them were infected with malaria parasites that harbour genetic mutations that have been linked to artemisinin-resistance in Southeast Asia.

The study noted that while these mutations have been documented in Africa in less severe cases, this was the first time they have been seen in parasites that were causing complicated malaria in hospitalised African children. The term “complicated” malaria is used to define cases where the disease is at risk of causing potentially life-threatening complications, like severe anaemia or brain-related problems known as cerebral malaria.

John said  researchers classified patients as suffering from partial resistance based on the WHO’s defined half-life cutoff for parasite clearance of more than five hours, meaning requiring more than five hours to reduce a patient’s parasite burden by 50 percent.

“Two children required longer than the standard maximum of three days of artesunate therapy because they failed to clear their parasites with three days of therapy,” he said, adding that, “longer treatment times increase the risk of poor outcomes.”  In Southeast Asia, the path to broadly resistant malaria parasites started with evidence of partial artemisinin resistance, and the concern is that this pattern will be repeated in sub-Saharan Africa.

The Ugandan children in the study received what is considered to be the gold standard for treating complicated malaria infections: an intravenous infusion of artesunate followed by oral treatment with an Artemisinin-based Combination Treatment (ACT) that combines another derivative of artemisinin, a drug called artemether, with the malaria drug lumefantrine.

John said the relatively high number of recurrent cases raises concerns that the efficacy of lumefantrine also may be declining. The drug is paired with artemether to make it harder for parasites to develop artemisinin resistance and also because lumefantrine stays in the body longer than artemether. Therefore, it can kill any remaining parasites not cleared by the shorter-acting artemisinin.

He said the study emerged from ongoing work in Uganda that is investigating outcomes of children who experience episodes of severe malaria. He said researchers pivoted to a focus on drug resistance because they noticed some children appeared to be slower to respond to the infusion of artesunate followed by an oral ACT.

“The fact that we started seeing evidence of drug resistance before we even started specifically looking for it is a troubling sign,” John said, adding that,  “we were further surprised that, after we turned our focus to resistance, we also ended up finding patients who had recurrence after we thought they had been cured.”

Against this background, what should be of concern to Africa’s health policy makers at this point is the fact that, if the situation in East Africa has called for concern, then, it means for a condition that is all over the continent, efforts must be put in place for the rest of the continent to save children. Our researchers must be up in arms.

It should not be left for people outside the continent to be helping. This is a problem for Africans to tackle and it must be so. We should not even be talking about financial constraints because if we want the money, it can be provided. It’s just a matter of our leaders, doing away with some of the comforts they enjoy in order to save lives.

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