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4f. Malaria: The Role of Medicines Retail Outlets in Improving Access to Medicines
Parasitological Assessment of Two-Dose and Monthly Intermittent Preventive Treatment of Malaria During Pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) in Lagos, Nigeria
1Nigerian Institute of Medical Research, Nigeria; 2Tropical Diseases Laboratory, Department of Medical Microbiology and Parasitology, College of Medicine of University of Lagos, Lagos, Nigeria.; 3Department of Obstetrics and Gynaecology, Ajeromi General Hospital, Ajegunle, Lagos State
Problem statement: IPTp-SP is a key strategy in the control of malaria in pregnancy, but there is paucity of data on the protective efficacy of IPTp-SP in Lagos, Nigeria. High SP resistance reported among Plasmodium falciparum isolates has been reported from clinical trials and molecular studies in children. This has necessitated the continuous monitoring of the efficacy of SP in pregnant women. Reports of malaria prevalence in Nigeria suggest that malaria is hyperendemic in most areas, thus raising concerns on the adequacy of the standard two-dose IPTp-SP strategy adopted for HIV-negative pregnant women.
Objective: To assess the equivalence of monthly dose to the standard two-dose IPTp-SP in Lagos
Design: The study was a longitudinal study. The women were randomly allotted to two arms: two-dose IPTp-SP (arm A) and monthly dose IPTp-SP (arm B).
Study population: A total of 259 pregnant women (arm A=122; arm B=137) attending antenatal clinics in two hospitals in Lagos, Nigeria, were recruited. Eligibility criteria were the absence of symptomatic malaria, HIV, and multiple pregnancy.
Outcome measures: Absence of malaria parasites in peripheral blood; proportion of live births and low birth weight
Results: Baseline parasitaemia (M0) in the two group was 5 (4.1%) and 3 (2.2%) in arms A and B, respectively. Majority of the women did not develop parasitaemia by M1 after the initial dose SP dose, (arm A, 98.3% in arm A and, 98.5% in arm B (P = 0.636). A similar result was obtained at the second month (M2) (P = 0.466); however, none of the women in the monthly IPTp-SP (arm B) developed parasitaemia after M1, whereas a woman became parasitaemic at M2 in the 2-Dose IPTp-SP group (arm A). The monthly dosing was not superior to the two-dose regime. The proportion of live births and low birth weight were similar in the two study arms (P>0.05).
Conclusion: Intermittent preventive treatment of malaria during pregnancy with SP is effective in protecting pregnant women from malaria infection in Lagos. Monthly dose IPTp-SP is equivalent to the standard two-dose IPTp-SP in Lagos, Nigeria.
Funding source(s): Personal finance of authors.
Access to Antimalarial Medicines: The Impact Malaria Approach
Problem statement: Effective malaria control programs require broad partnerships.
Design: The Sanofi Impact Malaria program is one of the initiatives of the Access to Medicines department. As such, it is based around 4 strategic levers: (1) a tiered-pricing policy that includes “no profit-no loss” prices for antimalarial drugs for the poorest patients; (2) a broad set of information and educational tools to promote comprehensive management of diseases; (3) partnerships to maximize impact; and (4) R&D programs to answer future medical needs.
Results: One of the key achievements of this program is the development, in partnership with the Drugs for Neglected Diseases initiative (DNDi), of a new, non-patented, antimalarial medicine—the fixed-dose combination of artesunate-amodiaquine (Coarsucam® or Artesunate-Amodiaquine Winthrop® [ASAQ Winthrop]). This medicine is specifically adapted to the needs of African patients, in particular children, who are the first victims of malaria. ASAQ Winthrop dosing is very simple (1 or 2 tablets, once a day, for 3 days) and tablets are dissolved in water. It was prequalified by WHO in 2008 and is registered in 30 countries in Africa and India. Among the Impact Malaria initiatives, two deserve a particular mention—(1) a complete offer of information materials and tools for the prevention and management of malaria, adapted to all the links in the healthcare chain, including scientific specialists, doctors, nurses, and community health agents, up to families and school children. By mobilizing the expertise of Sanofi and that of numerous partners, we help fight malaria on all fronts, according to our conviction that “drugs alone are not enough”; (2) an innovative field surveillance program of ASAQ Winthrop which contains several studies in diverse African countries, conceived in close collaboration with the National Malaria Control Programs of the concerned countries. With more than 20,000 episodes of malaria treated by ASAQ Winthrop, it is the most ambitious proactive program of pharmacovigilance ever launched in Africa for any type of medicine. Through this initiative, Sanofi contributes to building capacity in Africa in the field of pharmacovigilance, adapted to the needs and to resources of countries. This initiative is financially supported by DNDi and by Medicines for Malaria Venture (MMV). Since its launch in 2007, over 80 million ASAQ Winthrop treatments have been distributed in sub-Saharan Africa.
Conclusion: This success shows that this drug adequately meets the needs of patients and health care providers. It can also be attributed to the numerous partnerships developed by Impact Malaria and by its approach that promotes a comprehensive fight against malaria, beyond the provision of drugs.
Funding source: Sanofi, DNDi, MMV
Improving Access to ACTs Through Licensed Chemical Sellers in Ghana
1Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana; 2National Malaria Control Programme, Ghana Health Service, Accra, Ghana; 3Health Partners Ghana, PO Box AC 649, Accra, Ghana
Problem Statement: Artemisinin-based combination therapies (ACTs) are recommended for the treatment of malaria. In many endemic countries, ACTs are not readily available especially in rural communities where they are needed most. In Ghana, Licensed Chemical Sellers (LCS) are usually the first port of call for people seeking health care. LCS operate shops licensed to sell over-the-counter medicines as well as antimalarials. The Mobilize Against Malaria (MAM) project started in Ghana in 2008 to improve access to ACTs through LCS. The intervention involved training of LCS in treating malaria in children under age 5 and pregnant women, stock management, and referral of patients. The monitoring and evaluation component of the project involved regular annual surveys of LCS practices from 2008 to 2011.
Objectives: To measure the availability of antimalarial medicines stocked by LCS, knowledge of treatment of malaria, and referral practices.
Design: A questionnaire-based comparative descriptive study
Setting: LCS shops in selected communities
Study Population: LCS selected from six randomly selected districts in the Ashanti Region of Ghana for each annual survey in 2008(baseline), 2009, 2010 and 2011by cluster sampling based on census enumeration areas.
Intervention(s): Monitoring the effect of an educational intervention delivered by a third party.
Policy: Change in first-line treatment of malaria from chloroquine (CQ) to artesunate/amodiaquine(ASAQ) in 2005 and the introduction of intermittent preventive therapy in pregnancy using sulfadoxine/pyrimethamine (SP).
Outcome Measure: Effect of training on treatment knowledge; stocking and selling of SP and CQ; and referral patterns
Results: The number of LCS surveyed in 2008, 2009, 2010, and 2011 were 161, 160, 157 and 160, respectively. There was no difference in the number that had received training in general but there was a significant difference in the number that has received the project intervention between 2009 and 2010 (32.7% and 53.6%, p<0.001). The proportion of LCS stocking ACTs rose from 41% to 92.5% between 2008 and 2011. Knowledge of national treatment policy increasd from 41.6% to 84.7% in the study period. The proportion of LCS recommending ACT for malaria rose from 0% in 2008 to 70.6% in 2011. The most commonly sold malaria medicine by LCSs were ACTs by 79.4%. The variables studied were better (p<0.001) in the trained LCS. There was no change in the stocking of SP and sales increased from 2.5% to 14.7% between 2009 and 2010. Stocking of chloroquine dropped from 45.3% in 2008 to 15% in 2011. The stocking and sale of SP and CQ was not influenced by training. There was no change in the pattern of referral for children under age 5, 72.5% in 2009 and 64.3% in 2010 (p=0.1); and a fall to 48% in 2011. Referral forms were readily available in trained LCS in 2009, 2010, and 2011 (65.4%; 47.4%; 42.9% respectively).
Conclusion: There is increased availability and use of ACTs as a result of the MAM training. There was no change in the referral of children under age 5. LCS still stocked CQ and SP which was against national policy but the use of CQ had been significantly reduced.
Funding Source: Pfizer MAM Project
Medicine Outlets and Their Practitioners in Malaria Control in Ghana
1Kwame Nkrumah University of Science & Technology (KNUST), College of Health sciences, Kumasi, Ghana.; 2Affordable Medicines Facility-malaria (AMFm Unit), The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.; 3The School of Pharmacy, University of London, UK.; 4School of Pharmacy (Social Pharmacy), Faculty of Health sciences, University of Eastern Finland, Kuopio, Finland.
Background: Malaria is endemic in Ghana and contributes significantly to infant and maternal deaths. The pharmaceutical sector, and in particular medicine outlets, have been identified as accessible units in the health system, where public health initiatives could be targeted to facilitate greater access to effective tools and interventions for malaria control. Objectives: To assess the medicine outlets set up in both public and private sector facilities in Ghana and to investigate the availability of effective antimalarials and how practices within the outlets could be improved to support the national programme for malaria control
Methods: This study was cross-sectional involving 130 medicine outlets from hospitals/clinics and community-based retail outlets (i.e., community pharmacies and licensed chemical shops) in Ashanti and northern regions of Ghana. From these outlets, data were obtained to assess the available infrastructure and settings for pharmaceutical services, the staff resources available, their practices for malaria control, and the antimalarial products available. The indicators used were based on the national standards for pharmaceutical services, national policy for malaria control, and the WHO-led Roll Back Malaria initiative.
Results: The infrastructure and settings for pharmaceutical services were satisfactory in more than 80% of the outlets assessed. Non-policy recommended and mostly ineffective antimalarials were readily available and often supplied for malaria therapy, particularly in the retail outlets. The availability of policy-recommended antimalarials, in particular the artemisinin-based combination products, was rather poor (i.e., less than 45%). In addition few of the outlets (less than 10%) strictly adhered to policy recommendations for the selection and supply of medicines for malaria therapy. On-staff resources: Greater than 55% had no professional training as pharmaceutical service providers. The majority of the staff (greater than 80%), including both professionals and nonprofessionals, could recognise malaria illness and advise clients on how to avoid further infections, but few (20% and mainly professionals) were adequately skilled to both recognise and manage malarial illness as recommended by national guidelines.
Conclusions: The infrastructure and settings for pharmaceutical services were satisfactory but could be further improved and used to facilitate access to appropriate tools and interventions for malaria control. There were significant shortfalls, regarding the availability and supply of effective antimalarials. Furthermore, the majority of the medicine outlets’ staff were inadequately skilled to appropriately manage malarial illnesses. Pragmatic interventions should be directed toward the medicine outlets and their practitioners to enhance their contribution toward malaria control in Ghana.
Funding source(s): Information not provided