In an effort to reduce disease and deaths due to malaria, the government of Tanzania in 2006 issued guidelines on the treatment and control of the disease. The guidelines directed both state- and private-owned health facilities to use Artemether Lumefantrine (ALU) as the new first-line treatment for malaria. The guidelines suspended Sulfadoxine-Pyrimethamine (SP) as the first-line because SP had become ineffective in the control of Africa's leading killer disease.

According to Dr. Blaise Genton of Ifakara Health Institute (IHI), Tanzania, ALU had shown good results in the cure of malaria, particularly in Asian countries. Unfortunately similar results are not yet confirmed in the African setting. Based on the performance evidence from Asia and limited regional evidence, Tanzania decided to endorse ALU as the first-line treatment for malaria.

Scientists working with IHI saw the need to research on the effectiveness of this policy change in terms of reduction of disease and deaths due to malaria. IHI has initiated a project called Artemether Lumefantrine in Vulnerable patients: Exploring health impact (ALIVE).

The project covers the district of Kilombero in Mrogoro Region of Tanzania. The choice of the area was made based on the fact that IHI has a Demographic Surveillance System (DSS) in Kilombero District, Tanzania. This system is vital for collection of malaria disease related information and through it similar data have been collected in the past. Thus it was possible to use the data to compare the health situation before and after the introduction of ALU. “We know that ALU is an effective drug for the treatment of malaria, with more than 94% curative rate. It is an excellent drug but we want to see the overall control of transmission,” Dr. Genton confirms.

Dr. Genton and Dr. Abdunoor Mulokozi are the key researchers behind the ALIVE project. Dr. Mulokozi said the primary objective of the project is to assess whether the policy to replace SP with ALU has any significant impact in the reduction of both malaria disease and deaths as a result of malaria transmission.

The five-year project which will be concluded in 2010 monitors the impact of the introduction of the new policy on treatment of malaria by comparing data related to deaths before the introduction of ALU (2003/2004) and those after it was introduced (2006/2007). ALIVE is exploring whether ALU was the right policy choice for Tanzania given the varying circumstances in the management and treatment of malaria in an African setting.

Both reserchers acknowledge the challenge to elucidate the impact of ALU alone while there are many other parallel interventions taking place at the same time.

For instance in the communities where the monitoring is taking place, ALU and insecticide treated mosquito bed nets are commonly used.

The major research questions therefore are: to what extent has the use of ALU contributed to the reduction of deaths? Does the drug cause some complications to patients? How is the drug perceived by the population? “If ALU makes a difference in the number of people who die as a result of malaria then it will be the right choice that must be promoted,” says Dr. Genton.

Dr. Genton and Dr. Mulokozi agree that it is sometimes difficult to assess a countrywide policy implication if baseline data do not exist. The advantage IHI has is that it has high quality data collected already from the DSS in Ifakara,Tanzania.

Continous verbal autospy interviews are conducted in the DSS coverage area. “We sample more than 3,000 people per year and we test who has malaria as well as record the number of deaths due to malaria and other illnesses,” said Dr. Mulokozi. He adds: “during the crosssectional survey we go to households, offer them a chance to test for malaria.” Those found with malaria are immediately treated.

Building from past experience, ALIVE project monitors possible side effects of ALU. IHI conducted a formal training for health workers on how to report adverse effects of the drugs. Serious effects are then reported to the Ministry of Health and Social Welfare, and to Novartis Foundation. ALIVE project receives funding from Novartis Foundation.

Preliminary results show that people adhere to the instructions on how to use the medication and there are no traditional beliefs that are found to hinder the use of ALU. We found out that the perception on ALU is very good, the treatment is tolerable and nobody threw away the pills. Safety and impact studies are essential in making realistic study conclusions. The challenge we face in health research is to find the “right people to run the show,” concludes Dr. Genton.