In the last week of July the malaria community from the East and Southern Africa regions came together in Lusaka, Zambia for their annual planning and review meeting. This important meeting provides a forum to review the malaria control programmes of each of the 22 countries in the region and this year's specific theme was "Improving Malaria Diagnosis".
Despite all efforts, malaria continues to be a serious public health concern throughout the world and especially in Africa. It affects over 100 countries and approximately 40 per cent of the world's population. Of the 2.5 billion people at risk between 300 and 500 million become severely sick and over 1 million people die from malaria every year. In Africa, the worst affected continent, one in every five childhood deaths is due to the effects of the disease. The World Health Organisation estimates that an African child has on average between 1.6 and 5.4 episodes of malaria fever each year and every thirty seconds an African child dies of malaria.
Those who survive an episode of severe malaria are likely to suffer from learning impairment or brain damage. Pregnant women and their unborn children are also especially vulnerable to malaria, which is a major cause of stillbirths, low birth weight and maternal anaemia. The disease is not only a human tragedy; it is an economic one as well. The disease is estimated to cost the continent USD12 billion in forgone incomes every year and is estimated to reduce per capita incomes by 1.3 per cent per year.
All cases and deaths of malaria occur needlessly because the disease is entirely preventable and curable. Early diagnosis and prompt treatment are essential for those that fall victim to the deadly parasite. However, many primary level health care facilities in Africa lack the tools to detect the malaria parasite. Diagnosis of malaria is thus usually based on clinical symptoms such as fever, but due to the fact that many infectious diseases mimic malaria symptoms this approach leads to over-diagnosis rates of between 30-70 per cent - depending on malaria transmission patterns.
Over-diagnosis of malaria in turn leads to unnecessary antimalarial drug use which has the potential to lead to increased drug resistance and delays in achieving the correct diagnosis of the patient.
In the absence of a capable lab technician to conduct a microscopic analysis of a blood sample, a rapid diagnostic test (RDT), which takes approximately 15 minutes, provides a good alternative. The former is more accurate but takes time, requires a skilled lab technician and is more expensive than a RDT. However, without correct diagnoses we run the risk of losing a highly effective tool in the fight against malaria - effective antimalarial treatments.
Presently the malaria community only has one effective class of drugs (artemisinin-based combination therapies - ACTs) to treat the most severe form of malaria: plasmodium falciparum. To make matters worse due to the dishonest practices of some pharmaceutical manufacturers that are producing fake or substandard drugs there is an increased probability of resistance building up to the available ACTs. Africa Fighting Malaria recently released a report that was published in the Public Library of Science journal PLoS ONE. The report entitled Antimalarial Drug Quality in the Most Severely Malarious Parts of Africa - A Six Country Study reports on the tests AFM conducted to check the efficacy of drugs collected in six malaria endemic African countries namely: Ghana, Nigeria, Tanzania, Rwanda, Kenya and Uganda.
In the analysis, over 200 samples of antimalarial treatments were collected and tested to see if they met international standards. Overall 35 per cent of the samples were substandard and failed the test. This means that one in three patients is unlikely to be cured by the proclaimed antimalarial treatments purchased. Sub-standard drugs as opposed to outright fakes (where there is no attempt whatsoever to include the active ingredient) are of particular concern because in addition to affecting the patients' health,they also increase the probability of the malaria parasites building up resistance to good quality drugs. This has the potential of rendering an entire class of drugs useless, which in turn has serious long-term implications for our ability to fight the disease.
Given the precarious nature of the situation it is in many instances unfortunate that large multilateral donors are actively supporting and encouraging the domestic production of antimalarial drugs. First impressions may find the local production of drugs appealing, since it has the potential to decrease transportation costs, provide local jobs, increase expertise and cut dependence on foreign suppliers. However, apart from the potential for the production of fake or substandard drugs, local manufacturers may not be as efficient in production as other established manufacturers that are already supplying the market on a no-profit and no-loss basis.
In order to support inefficient and sub-standard home industries, a government may protect local manufacturers from foreign competition by imposing high tariffs on imported pharmaceuticals. At the same time, the government may offer tax incentives and subsidies to local companies. These constrict the supply of imported drugs, which are often of superior quality, without necessarily increasing local supply appreciably.
Despite the donor community attempting to increase access to medicines in developing countries through the development of local manufacturing facilities they should be cautious in their prescriptions, particularly if the wider policy environment in these economies is not conducive to the development of local facilities. Taxes and tariffs on pharmaceutical drugs and devices must be eliminated as a matter of urgency and strict regulatory standards must be adopted in order to clamp down on the production of fake and substandard drugs. It is thus incumbent on African governments to enforce laws on malaria treatment, to work to improve diagnosis and to use only high-quality artemisinin-based combination therapies.
South Africa was one of the first countries in the world to introduce RDT's to diagnose patients and it was also one of the first countries to change its first line treatment of uncomplicated malaria to ACT's. South Africa was able to do this because it does not rely on international funding for its malaria control programmes - it bases its decisions on scientific evidence that has been proven to work on the ground. South Africa's leadership in malaria control continues to be a beacon of light that other African countries strive to emulate and the South African department of health should be applauded for all of its work in malaria control.