MALARIA DRUGS-CONFUSION GALORE?  
Ask 10 people on the streets of Ghana’s capital, Accra, their choice of a drug to treat malaria. Ten different anti- malarials are likely to come up, both single and combination drugs. Eunice Menka, from Ghana, went to town to find out what is happening. “

I still take chloroquine and I have found it very effective in curing my malaria,” Mr Kofi Amarh, a Public Servant working with a government agency in Accra, says. He knows about the newly introduced first-line combination therapy, artesunate-amodiaquine. But says he still prefers taking 10 bitter tablets of chloroquine because of adverse drug reactions and habit.

Many Ghanaians still use mono-therapies such as alaxin and artesunate, despite the change to combination drugs because of doubts, habits and poverty. The big confusion raging on within the communities is: which anti-malarial is efficacious?

Majority of malaria suffers in the country do not visit health facilities at the onset of the disease. They prefer seeking treatment at the community drug shops and pharmacies. Worst still, most people prefer self medication.  

Ghana ’s statistics puts malaria as responsible for 40 per cent of all Out Patients’ Department cases but the disease is still a disease of the community and people prefer to treat it at home, especially if they have to queue at the health facility and spend more.  

This situation can be chaotic for people seeking relief from malaria judging from the variety of drugs around. While some people still believe in their “good old chloroquine” others believe the newly introduced anti-malarials, with all kinds of designer brand names, are the best.  

Chloroquine has failed in most African countries and the World Health Organization has asked that countries go for a combination of an artemisinin and other anti-malaria drugs for the treatment of malaria. Hence there is an official drive towards artemisinin-based combination therapy or ACTs on the continent.

Ghana has chosen to go for artesunate amodiaquine among the four ACTs recommended by the World Health Organisation. As always, big drug companies are having a field day pouring different anti-malarials on to the African market amidst the raging confusion, as patients are left on their own to wade through a maze of confusing anti-malarials. Mr Nelson Aklamanu, a Pharmacist at the Palace Pharmacy in Accra, says variety is needed to give options to people who react differently to drugs. Already, there have been some compliant from a section of the adult population of adverse drug reaction because of artesunate –Amodiaquine.

Mr Aklamanu says most adult patients who visit his pharmacy, opt for other malaria drugs, especially coartem, another combination therapy, because of adverse effects of sleeplessness, palpitation and weakness, they experience after taking artesunate amodiaquine. Surprisingly, he says children do not react adversely to artesunate amodiaquine. “It is well tolerated in children,” he says. “It should be possible to set up a trial into why children experience little side effects as compared to adult patients when they go on artesunate-amodiaquine,” he adds. People in Africa do not only have to contend with confusion in the midst of a variety of anti-malarials.

There are also questions of quality, safety and efficacy to deal with, for both imported and locally manufactured anti-malarials. These problems, if not dealt with head-on, could result in more trouble, more resistant strains, more ill health, and loss of man-hours in managing malaria. Some are questioning the role of regulatory bodies in this raging confusion. The Food and Drugs Board (FDB) in Ghana, has its hands tied. It only regulates the safety, efficacy and quality of drugs in the country and has no legal power to stop the manufacture or importation of any number of anti-malarials because of the free trade environment. Besides, Ghana is a signatory to various international conventions, and has to open its borders wide to allow for free trade.

It is gratifying therefore, that the FDB is no longer registering new anti-malarial mono-therapies now, as part of the official drive to effectively treat malaria through the use of combination drugs. The regulatory body says the registration licenses of mono-therapies, such as artesunate, chloroquine, amodiaquine, alaxin and halufantrine, already in the country, would not be renewed. The action of the regulatory body is in conformity with the policy directions to phase out the use of mono-therapies in favour of combination therapies in the management of malaria in Africa. But while FDB is carrying out its job, mono-therapies and the newly introduced combination therapies are jostling for space on community drug markets, including fake ones from neighbouring countries.  

Food and Drugs Administrations across the continent appear helpless in the face of countless anti-malarial from India, Nigeria and all parts of the globe. Some health experts have already taken issue with one of the latest ACTs recently launched in Morocco and targeted for the African market. The drug, asaq, a single pill, made out of artesunate-amodiaquine, has been described as an innovative product to treat malaria because it is cheap and easy to take. But worried health experts say it was launched in Africa, without rigorous scrutiny from the West, where systems are well developed. Since 2004, Sanofi-Aventis, a French pharmaceuticals, has been responsible for co-development, industrial production, registration and worldwide implementation of asaq. Critics of asaq say developers of asaq boycotted the stiff regulatory standards of the developed world and, with speed, got approval in Morocco, based on small scientific data. If the full benefits of combination therapies are to be realised in Africa, then African governments must effectively deal with the political, social, economic, legal, and cultural challenges to successful implementation of the introduction of ACTs. Having a better understanding of how these factors influence malaria treatment and policies should help in the provision of effective malaria management on the continent. It would also help people within the community make better choices in going in for efficacious anti-malarials, if the regulatory environment is firmly in place.  

Credit: KEMRI