Cambodia cracks down on illegal drug vendors in bid to counter antimalarial resistance

BMJ 2010; 340 doi: (Published 17 May 2010) Cite this as: BMJ 2010;340:c2622
  1. Peter Moszynski
  1. 1London

    The emergence of resistance to artemisinin derivatives in western Cambodia last year could prove a serious setback for international efforts to control malaria. In an attempt to counter the spread of resistance to the most effective remaining antimalarials, local authorities have cracked down on unlicensed pharmacies in the country, closing down more than 60% in the past six months.

    Shunmay Yeung, of the London School of Hygiene and Tropical Medicine, told the BMJ that Cambodia was where resistance to chloroquine first emerged in the late 1950s and that if artemisinin follows a similar path it would be “potentially disastrous for global malaria control.”

    Dr Yeung said that there are several reasons why Cambodia could be experiencing resistance to artemisinin. Although the country has become more stable, its history of political turmoil resulted in population movement, a weak public health system, and a largely unregulated private sector. The country has “a long history of artemisinin use, widespread availability of artesunate monotherapy, a lack of availability of effective fixed dose combination tablets, and a serious problem with fake and substandard drugs,” she said.

    Last year Cambodia’s Ministry of Health banned artemisinin monotherapy. This latest crackdown on unlicensed pharmacies was launched by a new inter-ministry committee to fight against counterfeit and substandard medicines, with assistance from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the World Health Organization’s International Medical Products Anti-Counterfeiting Taskforce.

    In January the health ministry ordered the closure of all unlicensed drug shops after monitoring of quality by the US Pharmacopeial Convention’s Promoting the Quality of Medicines programme showed that Cambodia’s unregulated private health sector was a source of large quantities of counterfeit and poor quality drugs.

    Last month the health ministry reported that the number of unlicensed pharmaceutical outlets had been reduced from 1081 in November 2009 to 379 in March 2010, a 65% reduction.

    Patrick Lukulay, the US programme’s director, said that although resistance had thus far only been detected in monotherapies of the artemisinin derivative artesunate—which was why the World Health Organization recommended that the compound should be used only in combination—resistance could eventually make artemisinin combination therapies ineffective too.

    He said there was now a concerted effort to contain the rise of resistance to artemisinin in South East Asia, because “the fear is that ACT resistance could spread to Africa, where the burden of malaria is huge.”

    Dr Lukulay said that Cambodia also needs to deal with other sources of substandard drugs, such as small street vendors, and that the only way to combat substandard drugs in the long term is “by bolstering the government’s own pharmacological surveillance programme to continue to monitor the quality of medicines on the market and shut down sources of poor quality medicines.”

    Dr Yeung said that it was essential to get effective co-formulated single tablet ACTs onto the market in Cambodia as soon as possible, “following years of delay.” But it was also important to provide free public health care to poor people in peripheral areas, who were the main customers of unlicensed drug vendors, she said.

    She said the enormous price difference between good quality ACTs and their less effective competitors “created huge incentives for criminals trading in monotherapies [and] substandard and fake drugs.” Ultimately what was needed was for the drugs to be made available more cheaply, which was why initiatives such as the Global Fund’s Affordable Medicines Facility for Malaria were so important.


    Cite this as: BMJ 2010;340:c2622


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