For decades quinine has been the main drug used in the battle against severe malaria across sub Saharan Africa and other endemic regions. Now there’s a newer treatment available to fight the severe form of the disease responsible for the loss of close to a million lives each year. The medicine is called artesunate and it’s recently been found to be more effective, easier to administer to patients and causes fewer side effects than the standard treatment, quinine. Young children under the age of five are much more vulnerable to dying from severe malaria and that’s why MSF is keen to encourage countries to roll out the new drug targeting this age group with the newer medication in their malaria treatment programmes. MSF's report "
"Making the Switch: A more effective treatment for severe malaria for young children" is now available and MSF is working to get the new drug adopted in treatment guidelines in Africa. Recently two year old Colette was rushed by her family to her local health centre in North Kivu in the Democratic Republic of Congo suffering from a really high fever, convulsions and difficulties in breathing – all indications that she was seriously ill with severe malaria Each year, 600 000 young children in Africa die of the illness despite the international attention paid to the disease.
Treating with quinine: Hard on the patient, challenging for health staff
Over the next few days, health staff battled to save her life with infusions of quinine – that’s when the drug is dissolved in a glucose solution and delivered through a drip into the veins of the patient. It’s the standard treatment for severe malaria in many African countries. But it’s a very difficult and complicated procedure for the young patient and staff alike, says local MSF paediatrician, Anja Juncker.
"Giving infusions to a small child can be very tricky and difficult; if for instance the child is dehydrated, the veins might collapse when you try to insert the catheter to set up the drip or you can’t even see the veins. And staff in the rural communities aren’t always well trained at doing this. So it takes several attempts to put in the intravenous line which causes the child a lot of pain."
Once the drip is established, each quinine infusion lasts for four hours and there are three infusions in a day. It’s a very skilled task to monitor accurately the dosage of quinine that each patient is receiving through the infusions over a 24 hour period and such skills are often not available in the health centres in more remote rural areas.
But getting the dosages wrong can cause the patient to experience a wide range of side effects – including dizziness, hearing loss, vertigo, nausea and vomiting. And if the patient doesn’t get enough of the drug, the malarial parasite will not be wiped out.
Colette was fortunate and escaped any of these problems. She’s gone on to make a good recovery to the delight of her family. But there are many more lives that could be saved if a newer drug, artesunate, could be introduced.
Artesunate: more effective, safer and much easier to administer
In 2010, the results of a landmark clinical trial carried out in nine African countries pointed the way to a better treatment for young children suffering from severe malaria. Artesunate is a very powerful medicine that reduces the risk of death by nearly a quarter. It’s also much safer with fewer side effects and, perhaps most importantly, can be administered by injection not infusion. Dr. Anja Juncker explains how this could really open up access to better treatment for severe malaria.
"The artesunate injection takes just four minutes to complete and delivers the exact dose of medicine to the patient. So that means the time to see that the medication is correctly administered is reduced from four hours to four minutes. This is a huge difference for the staff taking care of a patient. A treatment like this which is easier to administer and monitor means it could be made available in health centres in remote areas so that patient didn’t have to travel to hospitals when they fall ill."
The young patient too has a much better experience - he or she now gets one injection and then it’s all over and done with in four minutes until the next dose is required, rather than having to lie completely still for hours – very hard in the case of young patients in any case.
MSF & Malaria MSF provided malaria treatment to around one million people in 2010. Each year, around eight million simple malaria cases progress to severe malaria, where patients show clinical signs of organ damage, which may involve the brain, lungs, kidneys or blood vessels.
Making the switch to artesunate a reality on the ground
The scientific and medical case for bringing in artesunate as the main treatment for severe malaria in young children has been forcibly made. Now the battle starts to get endemic countries to adopt artesunate into their malaria treatment guidelines. Some African countries have shown interest but there is also reluctance – in some cases this is because of the initial higher price of artesunate – the basic unit cost of artesunate at the moment is three times that of quinine. However according to Nathan Ford, medical coordinator for MSF’s Access Campaign, this is a short-sighted view.
There have been cost effectiveness studies done in Asia and Africa that show the overall the difference in cost between artesunate and quninine is neutral because not only do fewer people die – which of course lessens the economic cost to the community - but you also save costs not having to deal with the side effects linked to quinine treatment and health workers are less occupied having to administer a complicated drug like quinine.
Old habits die hard and some countries in Africa - some of whom have stockpiles of quinine laid up for years to come – still require persuasion that the newer medicine is more beneficial than the treatment they have used for decades. To break down those prejudices, WHO will need to play a leadership role in pushing for the new treatment to be adopted at national level and offering the technical guidance and training to countries to make the switch happen. Nathan Ford thinks it’s a battle that can be won;
"This switch to artesunate is a very precise intervention that would bring a massive reduction in mortality. It’s not going to be an expensive policy change – it’s estimated it will cost around US$30 million per year to implement and will save two hundred thousand young lives a year. So this should be a very easy and winnable battle as long as there’s a clear international weight put behind the change. That needs to happen soon because today, almost every African country is still using quinine so they need a lot of assistance in the short term to save hundreds of thousands of young lives."