Dr Bernhards Ogutu tells us about the case management of uncomplicated malaria in Kenya, and the potential value of MFTs.
Diagnostic testing and prompt treatment – within 24 hours of onset – is required for the effective case management of malaria. In line with WHO recommendations, most countries have adopted ACTs, typically administered over 3 days, as the first-line treatment for acute, uncomplicated malaria. However, sustainable treatment strategies are needed to protect these valuable ACTs against the threat of resistance (alternatives to artemisinin derivatives are not expected to enter the market for several years).
One such strategy is the use of multiple first-line therapies (MFTs), which are made available in both the public and private sectors for physicians to choose from. By deploying multiple therapies – compared with only a single therapy – across the population, resistance to ACTs may develop at a slower rate.1-3
MMV and partners are implementing two operational feasibility studies involving MFTs. Following completion of an initial pilot study in Burkina Faso, a second study is now underway; and in Kenya, a pilot study is expected to begin in 2020.4 It is hoped that results from these studies will answer questions about the feasibility and logistics of MFT and eventually support broader policy changes in endemic countries.
How has the treatment landscape for uncomplicated malaria changed in Kenya over the last 20 years?
The malaria treatment landscape in Kenya has changed considerably. The transition from monotherapy with quinine to combination therapies is gaining traction, and health worker compliance has increased over time. Currently, artemether-lumefantrine is used as first-line treatment and dihydroartemisinin-piperaquine as second-line treatment for acute, uncomplicated malaria.5
Child-friendly, taste-masked products such as Coartem Dispersible6 have really helped to ease administration and improve paediatric case management. However, prescription patterns are not consistent. In the public sector, global funding mandates that quality-assured treatments are dispensed in accordance with international guidelines; however, in the private sector, which is less strictly regulated, older, less effective therapies may still be used.
What are the advantages of having MFTs available in malaria-endemic countries?
The biggest advantage of MFTs is that they can reduce the risk of resistance to currently available ACTs. MFTs can also prevent the use of outdated drugs. For example, artemether-lumefantrine, which is the first-line treatment in Kenya, is effective at clearing the blood-stage infection, but only provides a short duration of post treatment protection.
This means that if a patient shows symptoms of infection after completing a 3-day course of artemether-lumefantrine, physicians may perceive that the drug is not effective, and might switch to a more familiar, but outdated, treatment. If MFTs are available, physicians can choose another combination therapy and stay within the guidelines.
How has MMV helped to improve the case management of uncomplicated malaria in Kenya?
By bringing together various stakeholders from both endemic and non-endemic countries, MMV has changed the way new antimalarial drugs are developed. For paediatric medicines in particular, MMV has shifted the whole paradigm by establishing partnerships to bring forward palatable, child-friendly formulations, such as Coartem Dispersible. Without MMV, such progress would have been very difficult to achieve.
In Kenya, we are now starting to explore MFT pilots in partnership with the public and private sectors. MMV’s support in helping us prepare for an MFT feasibility study has been very valuable, and we look forward to seeing whether this new approach could help to improve the case management of malaria in Kenya.
1. Other research groups are exploring the potential of Triple ACTs (TACTs) to slow the spread of resistance.
2. Boni MF et al. ‘Benefits of using multiple first-line therapies against malaria.’ Proc Natl Acad Sci USA. 105(37):14216–21 (2008).
3. Boni MF et al. ‘The Community As the Patient in Malaria-Endemic Areas : Preempting Drug Resistance With Multiple First-Line Therapies.’ PLoS Med. 13(3):e1001984 (2016).
4. In collaboration with Prof. Gilbert Kokwaro, Director, Institute of Healthcare Management, Strathmore Business School, Nairobi, Kenya.
5. Pyronaridine-artesunate is currently under consideration for inclusion in the Kenyan National Treatment Guidelines.
6. Coartem Dispersible is a cherry flavoured formulation that dissolves in 10 ml of water.