Protecting our best weapon in treating malaria

Dr Margaret Chan
Director-General of the World Health Organization

Statement at the launch of the Global Plan for Artemisinin Resistance Containment
Geneva, Switzerland

12 January 2011

Ladies and gentlemen,

The report we are launching today sets out a high-level plan to protect our most potent weapon in treating malaria, the artemisinins. These medicines are the key ingredient of artemisinin-based combination therapy, or ACTs.

ACTs are the gold standard. They are the most effective treatment for falciparum malaria, the most deadly form of malaria.

Combination therapy is a deliberate strategy to delay the development of drug resistance, which inevitably happens when any antimalarial drug is widely, and especially, unwisely used.

ACTs deliver a two-punch attack on the malaria parasite. By combining drugs with different mechanisms of action and different time spans of activity, ACTs increase the likelihood that any parasites not killed by one drug will be killed by the second one.

The usefulness of these therapies is now under threat.

Evidence of resistance to artemisinins was suspected on the Cambodia-Thailand border in 2008 and confirmed in 2009. Other suspected foci have been identified in the Greater Mekong subregion, but are not yet confirmed.

This part of the world is the historical epicentre for the emergence of drug-resistant malaria parasites. History tells us what to expect.

Over the past several decades, we have lost one front-line antimalarial after another as resistance has developed, become established, and then rapidly spread internationally, rendering these drugs useless.

Today, in launching this global plan, WHO, together with Roll Back Malaria partners, is attempting to break this historical pattern. We are calling on the international community to take advantage of an unprecedented window of opportunity.

The ambition is bold: to stop the emergence of artemisinin resistance dead in its tracks, at its source, and thus prevent, or at least significantly delay, further international spread.

This opportunity is unprecedented in the history of malaria control. Why now?

Thanks to a recent surge in research, we understand malaria, and the mechanisms of drug resistance, much better. Let me thank researchers in hundreds of institutes around the world, also in endemic countries.

Their work has made it possible for WHO to compile the largest collection of studies on antimalarial drug efficacy ever reviewed and standardized for analysis.

Vigilance is at an all-time high. In fact, intensive monitoring of therapeutic efficacy has been in place, with WHO support, on the Cambodia-Thailand border since 2001. A standardized research protocol has been developed to aid similar vigilance elsewhere.

Never before have the first subtle changes in parasite sensitivity been detected so early. Never before have the tools and strategies been in place to attempt to stop the emergence and spread of drug resistance at its source.

Never before have we had such a high level of commitment to make this happen, to stay one step of ahead of at least some of the setbacks that history has taught us to expect.

We believe that the plan has every good chance of success. Above all, the international community is duty bound to seize this opportunity. Too much is at stake if we fail.

It is no exaggeration for me to say that the consequences of wide-spread resistance to artemisinins would be catastrophic.

After decades of stagnation in malaria control, stepped up efforts are finally producing impressive results, including striking drops in transmission rates and deaths. These results are invigorating, adding to the growing momentum to reduce the huge burden of malaria, especially in sub-Saharan Africa.

The spread of resistance to artemisinins and the loss of ACTs could unravel these hard-won gains very quickly and undermine the conviction that malaria can be defeated.

A large number of endemic countries have nothing left to fall back on if the ACTs begin to fail. Most older antimalarials have been rendered useless by drug resistance. While a major effort is under way to develop new classes of antimalarials, no replacement products are on the immediate horizon.

The estimated yearly number of malaria cases, though declining, is still 223 million. Leaving such a large number of people with no effective treatment would be an unthinkable tragedy.

Ladies and gentlemen,

I have two further points.

First, the containment plan is not a side-track, not a diversion of resources and efforts. Basically, what is recommended to contain resistance is what needs to be done to control malaria in every endemic country.

We need to continue to reduce transmission, through either the scaled up use of treated bednets or increased indoor residual spraying of insecticides.

Countries need to stop handing out ACTs to every child with a fever. ACTs should be treated like precious, fragile commodities, dispensed only on the basis of a confirmed diagnostic test.

This is entirely feasible. Inexpensive, quality-assured rapid diagnostic tests are now available that can be used right down to the community level.

We need to ensure that every patient with confirmed malaria gets the best, quality-assured medicines. We need to do more to prevent the sale of counterfeit or substandard medicines. We need to stop the practice of peddlers selling individual pills instead of full treatment courses.

We need to ban the marketing of therapies containing only artemisinin, and thus lacking that two-punch power of combination therapies.

These practices must be prevented as they hasten the development of drug resistance. They also undermine good overall malaria control.

My second point is this. We are launching a global plan at the start of 2011, but this does not mean that aggressive action has not already taken place. On the contrary.

Containment efforts began immediately on the Cambodia-Thailand border at the end of 2008, even before resistance was confirmed. Household coverage with treated bednets is nearly 100%.

Health facilities have been set up to diagnose and treat malaria. Services are open 24 hours a day, free of charge, and stocked with quality-assured ACTs. Intensive monitoring of therapeutic efficacy continues.

What the global plan aims to do is add another safeguard by extending vigilance and preventive measures to all endemic countries.

The emergence of artemisinin resistance has been a wake-up call. It gives us another compelling reason to step up existing control measures with the greatest sense of urgency.

The global plan spells out clearly what needs to be done. It is my sincere wish that the international community will seize this unprecedented opportunity.

Thank you.