Transcript Stand of anti-malarial drug resistance in Lao P.D.R. an country report

Current National Drug Policies in
Lao P.D.R.
By Dr Samlane Phompida
Centre of Malariology, Parasitology &
Entomology
Antimalarial drug resistance
• Chloroquine: CQ
– 1999: 46% treatment failure (33% RII/RIII) in VP
– 2001-2002: 30-55% treatment failure in SVK, ATP, LN
• Sulfadoxine-pyrimethamine: SP
– 2001: 18-35% treatment failure in SVK, ATP
– 2002: 11% treatment failure in CPS (4% ETF, 7% LPTF)
• CQ+SP:
– 2001: 16-22% treatment failure in ATP
– 2002: 8% treatment failure in SVK
• Mefloquine: MQ
– 2001: 100% ACPR in ATP (14 days follow up)
• Artesunate+mefloquine:
– 2002-2003: 100% ACPR in SVK and LN (42 days follow up)
• Artemether+lumefantrine:
– 2002: 97% ACPR in SVK (42 days follow up)
– 2003: 93% ACPR in LN (42 days follow up)
• Artekin(Dihydroartemisinin+piperaquine)
– 2004: 93% ACPR in SVK (42 days follow up)
Phetsouvanh,R.Pnompenh
2000
2
Antimalarial drug resistance
in LAO PDR
2001-2002 : CQ : TF : 30-55 %
2001
: AS+ Mef :ACPR : 100%
2003
Coartem : ACPR 93%
1999 : CQ : TF : 46 %
RII/RIII : 33 %
2001-2002 :
2001
:
2002
:
2002-2003 :
2002
:
CQ:TF: 30-35 %
S/P :TF: 18-35 %
CQ+S/P : TF : 8 %
AS+Mef : ACPR : 100 %
Coartem : ACPR 97 %
2001 : S/P :Tf : 18-35 %
: CQ+S/P : TF : 16-22 %
; AS + Mef : ACPR : 100 %
2001-2002 : CQ: TF : 30-35 %
Phetsouvanh,R.Pnompenh
2000
N
3
Proposed sentinel sites for in-vivo study in Laos
Sentinel sites for drug monitoring in Lao PDR
Louangnamtha
Houaphanh
Louangprabang
Savannakhet
Attopeua
Phetsouvanh,R.Pnompenh
2000
4
Past anti-malarial drug policy
in Lao PDR
• Laos has adopted one treatment policy of
malaria for different levels of health facilities
system
• Chloroquine or sulfadoxine/pyrimethamine for
the treatment of uncomplicated malaria
• Quinine i.v. for complicated malaria and in case
of treatment failure with CQ or SP.
• 1st line treatment (CQ) was available at village
level
• Enable VHWs in the correct treatment of
uncomplicated malaria based upon clinical
signs.
• Enable central-, regional-, provincial-,district
hospitals to diagnose and treat complicated
malaria correctly
• Regular monitoring of resistance to antimalarial drug/ combinations at sentinel sites
• National policy included chemoprophylaxis for
pregnant women and vulnerable groups, but
implementation limited
Antimalarial drug resistance situation
• 2001-2002:
–
–
–
–
–
40-78% of failure to CQ (14/28/42 days)
18-36% of failure to SP (42 days)
8% of failure to CQ+SP (42 days)
92% of efficacy of Coartem® (42 days)
100% of efficacy of A+M (42 days)
• 2003:
– 94% efficacy of Coartem® (42 days)
– 100% efficacy of A+M (42 days)
Response to drug resistance
• Round table to discuss on the treatment policy (2003)
• Introduction of CQ plus SP as interim policy
• Change of policy to combination therapy: Coartem
with the use of RDTs, esp at district and village level,
free of charge to the patient
• Registration of Coartem blisters only use by NMCP
• Definition of 4 categories of weight and age
• Launch of procurement of ACT through WHO in
December 2003
• Production of guidelines on the use of RDT and ACT
• Production of IEC materials on the use of ACT
• TOT (incl on RDTs) in 3 pilot provinces (SRV, SK,
ATP) in 2004, expanded to all provinces in 2005
Different options and alternatives
• Artesunate+mefloquine
– First choice
– Procurement issues: no product available meeting
international GMP standards
• Alternative ACTs
– Coartem® was adopted as 1st line treatment by
Taskforce. Inform GFATM on change in policy,
register Coartem, define weight and age dosages,
produce new guidelines, new IEC materials, reorganize TOT on Coartem
– Artekin® : not currently WHO-recommended
What is the future in malaria
treatment in Lao PDR?
New Malaria Treatment Policy,
Lao PDR:
• 1st line: Artemether + Lumefantrine (CoArtem)
– all levels of health services
• 2nd line: Quinine + doxycycline
• Severe and complicated malaria: inj. Artesunate
or quinine
• Small children: artesunate supp.
• Pregnant women: quinine or artesunate (from
2nd trimester)
Implementation of the new policy
• In 2002/2003 ACT was firstly introduced and
closely followed up in 3 southern provinces of
Laos: Attopeu, Sekong and Saravane where
mortality and morbidity to malaria are high and
evidence of DR is available.
• Implementation of ACT focuses on provincial
and district hospitals including health centers.
• In pilot areas it is also implemented down to
village level.
• In 2005, begin of countrywide implementation
• Efficacy monitoring of new policy continues in
the 3 Lao sentinel sites, and regular review of
results will be conducted
• As the combination is expensive (2.4US$ per
adult dose) therefore it is required to perform a
malaria test (microscopy or dipstick) and
treatment is given only to P.f positive patient
Thank You for your attention!