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PAPERS: Chantal M Morel, Jeremy A Lauer, and David B Evans Cost effectiveness analysis of strategies to combat malaria in developing countries BMJ 2005; 331: 1299 [Abstract] [Full text]

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Corrigendum

Chantal M Morel   (20 December 2005)

The question is which ACT should we use?

Jacques D Charlwood   (16 February 2006)

Corrigendum 20 December 2005
Chantal M Morel, Research Fellow London School of Hygiene & Tropical Medicine Send response to journal: Re: Corrigendum	Corrections should be made to Table 3 and Web Table 2: 1) R (starting resistance) of Case management with Chloroquine should be 0.35 (it was 0.3) 2) Adherence for Case management with non-artemisinin based combination treatment should not have a symbol. 3) Probability of success when not fully compliant for Case management with non-artemisinin based combination treatment should be 35% (it was 45%). 4) Adherence for Case management with artemisinin based combination treatment should be 35% (it was 40%) It should not have a symbol. 5) Probability of success when not fully compliant for Intermittent presumptive treatment with SP in pregnancy should be 0% (it was 10%) Competing interests: None declared
The question is which ACT should we use? 16 February 2006
Jacques D Charlwood, research fellow Morrumbene Mozambique Send response to journal: Re: The question is which ACT should we use?	It was interesting to see that Morel et al (2005) agree with the analysis of Mills & Shillicutt (2004) who, as part of the Copenhagen Consensus concluded that Artemisinin-based Combination Therapy (ACT) is the most cost effective malaria containment strategy available for Africa today. The difficulty lies in knowing which combination to use. Many of the benefits of artesunates (in particular the rapid improvement in symptoms) are not available with Co-artem ® (the most widely touted and most widely available ACT today) since this only has a low dose of artemisinin. It is also not certain if a rapidly excreted high dose of artesunates is more, or less, likely to lead to the development of resistance compared to several days of low level dosage (as occurs with Co-artem ®). Other co- formulated combinations (such as Co-arinate®) have a sulphonamide as the long acting partner drug. The main difficulty here is that in many areas parasites are already resistant to the second candidate drug to be used in the combination. The alternative is that the ACT comes as separate pills in blister packs (which avoids the long and expensive process of testing and registering the combination product). In this situation, however, then there is always the chance, indeed the likelihood in the case of artesunate+amodiaquine combinations, that patients will not take or complete treatment with the second drug. So where does that leave us? WHO recently issued a list denouncing manufacturers who sell mono-therapy of artemisinin since, they claim, that this will lead to resistance. Living as I do in a village in Mozambique where malaria transmission is intense and where it is impossible to avoid getting infected, I say ‘Thank goodness artesunate (as mono-therapy) is available in the nearby town pharmacies’. As a result I am able to perform ‘home-grown’ ACT. Judicious use of the artesunate with a second, locally available, drug has probably saved my life several times. My neighbours could and might do the same if they know what the best combination might be. The key therefore, apart from the price – which is indeed beyond the reach of most people – is knowledge and information. Rather than bemoaning the manufacturers of mono-therapies, it behoves the WHO to issue the information on what over-the- counter mono-therapies to combine to provide the best cure rate. After all the drugs are already out there and, as I wrote in 1984, ‘ultimately the way to improve health standards in the world is to make people aware that they can look after themselves and to give them the wherewithal for doing so’. Sincerely, JD Charlwood MOZDAN Project, P.O.Box 8, Morrumbene, Inhambane Province, Mozambique References Charlwood JD. Which way now for malaria control, PNG Med Journal 1984 27: 159-162 Mills A & Shillcutt S. Communicable Diseases Chapter 2 in Global Crises, Global Solutions. Lomborg B ed Cambridge University Press 2004 Chantal M Morel, Jeremy A Lauer, and David B Evans Cost effectiveness analysis of strategies to combat malaria in developing countries BMJ 2005; 331: 1299 Competing interests: None declared