WHO African Region: Ethiopia

ACT Drug, artemether-lumefantrine recommended for the treatment of uncomplicated malaria

Executive summary

A workshop on the anti-malaria treatment policy in Ethiopia was convened 25 – 26 May 2004 in Addis Ababa. The objective of the workshop was to discuss on the current level of the therapeutic efficacy of sulfadoxine-pyrimethamine and safety and efficacy of artemether-lumefantrine for the treatment of uncomplicated malaria and to recommend actions required in light of the findings.

The workshop was attended by 90 participants from Regional Health Bureaus, Academic and Research Institutions, specialized referral hospitals, UN organizations, civil societies and NGOs participating in malaria prevention and control in Ethiopia. Cognizant of the high treatment failure rates of sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria detected in a study conducted from October to December 2003 in 11 sites, (mean treatment failure 35.9%, range 21.7-53.4% on 14-days follow-up and 71.8%, range 53.8 – 85.7, on 28-days follow-up, not PCR corrected), the workshop participants reached consensus on the need to review the current malaria diagnosis and treatment policy.

The safety and efficacy baseline information on artemether-lumefantrine was also conducted in 4 sites by enrolling 213 subjects. After a follow-up period of 14 days, no treatment failure cases and drug side effects were reported.

Based on the drug efficacy study findings, therefore, the need to change to the use of the ACT drug, artemether-lumefantrine for the treatment of uncomplicated malaria was recommended. Moreover, strengthening the diagnostic capacity in health facilities where microscopy is not available, including introduction of rapid diagnostic tests (RDTs), hasten resource mobilization efforts to meet the high cost of the new ACT drug and efforts to strengthen selective vector control, including ITNs, were strongly recommended.

Recommendations

  • Revise the malaria diagnosis and treatment guideline based on the recommended anti-malarial drugs and conduct training of health workers as early as possible,
  • Ensure supply of Artemether-Lumefantrine in a prioritized order by targeting first, last year epidemic affected districts, resettlement areas and other at risk districts,
  • Strengthen the laboratory diagnostic capacity of health facilities and ensure use of RDTs for malaria diagnosis in peripheral health facilities where laboratory service is not available,
  • Treatment using Artemether-Lumefantrine should preferably be based on definitive diagnosis. Therefore, efforts to expand diagnostic facilities should be strengthened. Until such time, community level early referral of cases to health facilities by CHWs should be strengthened,
  • Strengthen communication to the public for behavioral change in early treatment seeking and use of ITNs and protection of sprayed houses from re-plastering,
  • Conduct study on the ease and feasibility of use of rapid diagnostic tests (RDTs) at home and community level,
  • WHO recommends IM Artemether for the management of severe & complicated malaria cases in peripheral areas during epidemics. Therefore for the treatment of severe & complicated malaria in visceral Leishmaniasis patients (as both SSG and quinine are cardio-toxic) and for the treatment of severe malaria in malnourished children in drought affected areas, and during malaria epidemic IM Arthemeter should be pilot tested and introduced if the findings support so,
  • Conduct comparative evaluation on the efficacy, cost, ease of administration, side effects …etc of other ACTs such as Artesunate + LAPDAP, Artesunate + Amodiaquine, Artesunate + Pyronaridine and Dihydroartemisinin + Piperaquine for the treatment of uncomplicated malaria and Chloroquine + proguanil for chemoprophylaxis,
  • Investigate the efficacy of artemether-lumefantrine for the treatment of vivax malaria,
  • Conduct local studies in collaboration with medical and research institutions for the identification of ACT drugs suitable for the treatment of malaria during pregnancy,
  • Customs clearance of drugs is a responsibility of FMOH/PASS – additional focal responsible person/s need to be assigned especially for ACTs and RDTs as the drugs & test kits have short shelf life (2 years) and are affected by heat easily,
  • In light of the short shelf life of the ACT drug and RDTs, distribution from central to regions, districts and health facilities requires swift action than the traditional approach. To ensure this FMOH, RHBs, and district health offices should work with partners that can assist in logistics.