Multiple first-line treatment options for uncomplicated malaria

In 2001, the WHO recommended artemisinin-based combination therapies (ACTs) as first-line therapy for uncomplicated malaria, a decision largely driven by the devastating emergence of resistance to existing therapies (chloroquine and sulfadoxine–pyrimethamine) in Asia, Africa and Latin America.¹

Currently, the WHO recommends six ACTs for the treatment of uncomplicated Plasmodium falciparum^2,3 malaria, creating a pool of antimalarial medicines for uncomplicated malaria which healthcare workers in the public and private sectors can choose from. This is referred to as a multiple first-line treatment (MFT) policy and is a pre-emptive approach to drug-resistance management.

In this interview, Dr Mohamadou Siribié discusses the MMV-supported pilot MFT evaluation in Burkina Faso.

1. What are the inherent challenges and advantages of an MFT approach for the treatment of uncomplicated malaria?

MFT reduces pressure on the use of a single ACT and increases the therapeutic life of multiple ACTs, which are both critical in the fight against malaria. MFTs also improve access to a range of ACTs in endemic settings. In terms of challenges, the acquisition of sufficient ACTs for use in MFT can be difficult in a real-world setting. Managing ACT distribution and prevention of stockouts are other required considerations. The training of health workers and setting up supportive monitoring at a health facility level can also be challenging.

2. Could you briefly describe the formative phase of the MFT pilot evaluation in Burkina Faso?

The formative phase of the pilot evaluation included the generation of baseline information and the development of tools for implementation. Baseline information included perception and expectation of MFT strategy by health system stakeholders and community members. In addition, it aimed to document any perceived/existing obstacles to implementation, treatment-seeking behaviour for febrile episodes/malaria, and morbidity and mortality rates in the pilot evaluation area. ACTs were delivered according to patient category (e.g. pregnant women) and age (adults/children).

3. Who were the partners you worked with and how was it conducted?

In Burkina Faso, a consortium was set up to conduct this pilot evaluation. The leading research institute in the consortium is the Groupe de Recherche Action en Santé. The Institut de Recherche en Sciences de la Santé is a second research institute that evaluates the effects of the programme through its health and demographic surveillance system that covers part of the pilot evaluation area. An additional partner is the Ministry of Health of Burkina Faso through its technical department, the National Malaria Control Programme. This serves as the main link between the researchers, the central drug store in the country and the national health system. This work is possible with the financial and technical support (i.e. protocol development and monitoring of activities) of MMV.

4. How easy/difficult was it for the health workers to accept the MFT protocol?

It was relatively easy in the evaluation area. Malaria is one of the top 10 diseases in Burkina Faso, so health workers are familiar with the management of uncomplicated malaria. Health workers included in the evaluation were retrained on malaria diagnosis, prescription of ACTs (especially the newer combinations), pharmacovigilance and management of ACTs prior to deployment. The health workers benefitted from supportive monitoring visits from the health district management and research teams. The main difficulty was the turnover of health workers involved in implementation, which could have affected their compliance with the evaluation protocol. Fortunately, this has been mitigated by hands-on training for the new staff.

5. What has the pilot evaluation revealed so far?

We have just completed the evaluation phase of the pilot. According to preliminary data, approximately 81,000 malaria episodes in children under five years old benefitted from pyronaridine–artesunate treatments, 4,700 malaria episodes in pregnant women benefitted from artemether–lumefantrine, and 90,000 malaria episodes in individuals five years and older benefitted from dihydroartemisinin–piperaquine administration. So far, no serious adverse drug reactions have been reported.

6. From your perspective, how could the use of MFTs benefit Burkina Faso’s malaria control programme? How could it support the country’s efforts to eliminate malaria?

Currently, the Burkina Faso malaria treatment guidelines recommend three ACTs – amodiaquine–artesunate, artemether–lumefantrine and dihydroartemisinin–piperaquine. Only artemether–lumefantrine is available at the health facility level for treating uncomplicated malaria. Our pilot evaluation offers additional ACTs at this level and is the first opportunity for distributing two additional ACTs (dihydroartemisinin–piperaquine and pyronaridine–artesunate). National guideline revision is underway, and our evaluation has been instrumental in promoting the future adoption of pyronaridine–artesunate. Pilot evaluation data will be made available to policy makers and we hope this data will be used to scale up MFT if results are positive.

7. What has it been like to work with MMV on this pilot evaluation?

This has been my first opportunity to work with MMV and I greatly appreciate our collaboration. We look forward to reporting successful results and continuing our work with MMV on future research in Burkina Faso.

1. World Health Organization. Antimalarial drug combination therapy. Report of a WHO Technical Consultation, 4–5 April 2001. WHO (2001).

2. Guidelines for the Treatment of Malaria. 3rd Edition. Geneva: World Health Organization; 2015. https:// pubmed.ncbi.nlm.nih.gov/26020088/

3. The use of artesunate-pyronaridine for the treatment of uncomplicated malaria. WHO. 2019. Available at: https://apps.who.int/iris/bitstream/handle/10665/328762/WHO-HTM-GMP-201…