Tanzania's Ministry of Health and Social Welfare has released new guidelines on the treatment of severe malaria. This time, the policy guidelines introduce artesunate injection to replace quinine injection. Dr. Irene Masanja, a research scientist at Ifakara Health Institute, has been involved in advising the ministry on effective tools to fight malaria. In an interview with Mbarwa Kivuyo of AMMREN Tanzania, Dr. Masanja explains the shift from quinine to artesunate injection and the future of quinine.
AMMREN: You advise Tanzania's Ministry of Health and Social Welfare on malaria treatment policies. How did you get this very important task?
A: My involvement with malaria control at the Ministry of Health began in 2002 when I joined Ifakara Health Institute (IHI). Tanzania had changed malaria treatment policy in August 2001, replacing chloroquine with Sulphadoxine –Pyrimethamine (SP) as the first line treatment of uncomplicated malaria.
During that time the US Center for Disease Control established a collaborative agreement with IHI, to introduce artemisinin-based combination therapy (ACT) using SP + Artesunate in one area and SP alone in another area. I was also employed by the USAID's IMPACT project in Tanzania to assess the policy implementation process. Later, I worked on the district implementation of malaria rapid tests 2006/7 and 2008/9, before it was adopted as a national policy. That is how I got to be involved in malaria advisory role.
AMMREN: What did your work with IMPACT entail?
A: Here, we evaluated how providers were complying with the new treatment recommendations and what challenges they were facing. In the course of these jobs, we regularly had meetings with the malaria control programme officials to share findings and concerns from these surveys, as well as learning from them details of the new malaria treatment guidelines.
AMMREN: What is your specific area of competence in this advisory role?
A: My involvement is mainly in the malaria case management cell which deals with malaria diagnosis and treatment; including chemoprevention of special groups such as intermittent preventive treatment (IPT) in pregnant women. To be more specific, I am one of the national trainers on malaria diagnosis and treatment.
AMMREN: At the MIM conference in October 2013 in Durban, South Africa, you won two prizes for emerging scientists. Do these awards come as a result of your work in advising the government of Tanzania on treatment policies?
Yes, in Durban I received two prizes. First, for one of the top 10 best presentations, along with my team in Ifakara Health Institute (Tanzania), Swiss TPH (Switzerland), CDC, Atlanta (USA) and INDEPTH Network. The second award was the overall Best Emerging Scientist aged below 40. This work was a multi-country study supported by the Bill and Melinda Gates Foundation, which established a Phase 4 platform to assess the safety and effectiveness of antimalarials in use. The evaluation was done in two Health and Demographic Surveillance System (HDSS) sites in Tanzania and three sites in Ghana. Findings from all these work are fed into the malaria control programmes of respective countries in order to help in policy formulation and better care for the people.
AMMREN: Where did you get evidence to recommend that the previous malaria treatment policy be changed?
A: Research demonstrated the superiority of artesunate injection against quinine injection in the treatment of severe malaria. Two main studies conducted in Asia (SEAQUAMAT) and Africa (AQUAMAT) provided the much needed evidence which prompted the World Health Organization (WHO) to change guidelines for the management of severe malaria and support member countries to do the same.
AMMREN: What is the future of quinine?
A: Quinine is not completely out of the new treatment guideline. It is still a recommended medicine of choice for management of malaria in women in their first trimester.
AMMREN: What is the cost of introducing the new severe malaria treatment policy?
A: The cost of introducing new treatment policy for a disease which is a leading cause of hospital attendance is quite enormous. I think it is too soon to answer this question because the national roll-out has just started and it is scheduled to occur in two phases. The Ministry of Health is still implementing the first phase that involves hospitals and health centres before moving to dispensaries. But, we have some experience through the previous change and many researchers have published on the cost of introducing new malaria treatment guidelines at district or national level. Some of these works were undertaken by colleagues from IHI during the IMPACT –Tanzania study.
AMMREN: Is the Ministry of Health and Social Welfare well equipped to introduce and implement this new policy at different levels?
A: You see the Ministry of Health and Social Welfare has a supervisory role on policy formulation, dissemination and implementation of the new treatment policy. They supervise the process of revision and formulation of treatment policies with technical support from many stakeholders, in and outside the country. They also have the mandate to disseminate to all responsible actors, train regional trainers and supervise training at regional and district level. However, implementation of the policy is the responsibility of the local government authorities at regional and district levels. The Ministry of Health continues to provide technical support to local governments throughout the implementation and use of treatment guidelines. So, I will say, yes, they are well equipped to effect the implementation of the new treatment policy, because they have the needed technical expertise.
AMMREN: Why is Tanzania experiencing rapid malaria treatment policy shifts?
A: These changes are in line with what is happening in the scientific world. New evidences are emerging every day and the health ministry strives to keep pace with evidence-based policy decisions. ACT is still the treatment of choice for uncomplicated malaria, since introduction in 2006. In the current revision, other ACTs are named as alternative treatment. The main change in the present revision is the management of severe malaria with injection artesunate. So, you see, new changes are introduced only when it is necessary and there is enough evidence that they improve the quality of care.
AMMREN: Does Tanzania have WHO's blessings to introduce injectable artesunate?
A: The WHO changed the guidelines to recommend use of injection artesunate for treatment of severe malaria about 2-3 years ago. So, these changes are supported by the WHO, and in fact they also provide technical assistance whenever needed to do so.
AMMREN: Which countries other than Tanzania in the malaria endemic zones have introduced the injectable artesunate?
A: Apart from Tanzania, several other African countries have also started to use injection artesunate for treatment of severe malaria. I know of Uganda, Malawi, Nigeria, and I think Ghana too.
AMMREN: What lessons can we draw from the experiences?
A: In general, injection artesunate has been very well received in many countries. We at IHI are collaborating with CDC - Atlanta and National Malaria Control Programme (NMCP) with support from US President’s Malaria Initiative (Tanzania). We introduced injection artesunate in Pwani region in 2011/12, which was an experience that is difficult to forget. Unfortunately, Pwani is still among the regions that record high malaria cases including severe cases of the disease. Some health providers referred to injection artesunate as a miracle drug. I remember one medical officer-in-charge of a district hospital saying to me over the phone “…with this medicine, children whom in the past we received and knew wouldn't survive, are now recovering in less than 24 hours…” From that regional-wide pilot implementation of injection artesunate, we witnessed and heard many good testimonies.
AMMREN: How do you assess the current malaria situation?
A: The burden of malaria is declining in most malaria endemic areas owing to the scaling up of interventions to prevent and control the disease. Knowing that development of insecticide and antimalarial resistance can hinder these achievements, the malaria scientific community needs to stay ahead of the game. It is necessary to equip health systems in low income countries to scale up necessary interventions, have surveillance systems in place and comply with treatment policy recommendations that include universal coverage of parasitological diagnosis of malaria before treatment with ACTs. We have learnt that, laxity in malaria successes have almost always led to resurgence of the disease.