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Can ALU conquer Malaria?

By Mbarwa Kivuyo, Tanzania

In  an  effort  to  reduce  disease  and deaths   due   to   malaria,   the Igovernment  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.

T h e   m a j o r   r e s e a r c h   q u e s t i o n s   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.

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