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Papers Achieving the millennium development goals for health

Cost effectiveness analysis of strategies to combat malaria in developing countries

BMJ 2005; 331 doi: (Published 01 December 2005) Cite this as: BMJ 2005;331:1299

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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

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’.


JD Charlwood

MOZDAN Project,
P.O.Box 8,
Inhambane Province,


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

Competing interests: No competing interests

16 February 2006
Jacques D Charlwood
research fellow
Morrumbene Mozambique