Can Asia save Africa from drug-resistant malaria?

By Jonah Fisher
BBC News, Sai Yok, Thailand

Image caption,
Villagers on Thailand's border with Burma are tested for drug-resistant malaria

In a wooden hut on the Thai-Burmese border, a community health worker pricks the finger of six-month-old Tannakorn, who lets out a whimper.

Fifteen minutes and a blood test later, his mother is given good news. Tannakorn's fever is not malaria and he can go home.

It is an unremarkable exchange, repeated thousands of times every day in South East Asia and around the world.

But in the last year, the work of this clinic in Sai Yok district and those nearby have assumed an importance that goes far beyond the local.

This is now the frontline in the fight to stop South East Asia's drug-resistant malaria going global.

Earlier this year, scientists announced that strains of malaria that resisted the most widely-used treatment had been confirmed in two locations in South East Asia

One has been known about since 2006, straddling Cambodia and eastern Thailand. The other, newly verified, was in the west where the mountains of Burma and Thailand join.

The news sent a shudder through international agencies leading the fight against the disease.

Since 2003 the amount of money spent tackling malaria has risen more than eight-fold. The multi-billion-dollar campaign is acknowledged as one of the world's public health success stories.

The funding increase, largely through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the use of bed nets, rapid test kits and effective treatment have led to a steady fall in the number of people both infected and dying. Some estimate that more than 750,000 lives have been saved.

In Africa, which accounts for 90% of the world's malaria fatalities, the number dying each year has dropped by a third and talk had begun to turn to the possibility of totally eradicating malaria by 2015.

For the last 15 years, the most effective and widespread drugs used against malaria have been derived from a Chinese plant, artemisia annua.

When used quickly and effectively, artemisinin-based combination therapy (ACT) as it is known, has proved highly effective in clearing the bloodstream of the plasmodium falciparumparasite that cause most cases of malaria - usually within three days.

Stopping drug resistance spreading means monitoring those who have been treated, and hitting any parasites that survive with a second line of treatment before they are passed on to others.

Financial incentive

Image caption,
Witthaya Saipomsud collects data to monitor the level of drug-resistant malaria parasites

In rural Thailand, where many walk for miles to reach the clinic, getting people to return for follow-up tests has not been straightforward.

But thanks to increased interest and international money, Witthaya Saipomsud, who oversees many of Sai Yok's clinics, has since February been able to offer a financial incentive.

If a malaria patient completes a series of blood tests up to 28 days after the first treatment, they get 1,000 baht ($30, £18.70).

"We did follow up tests on 190 of our Falaciparum malaria patients this year. After 28 days, 40 still had malaria parasites," Mr Saipomsud says.

It is a worrying drop in the effectiveness of the artemisinin-based drugs, and with 40% of the patients coming from Burma, a worrying snapshot of the situation there.

Thanks to the efforts of health workers like Mr Saipomsud, and the widespread availability of treatment, malaria still only kills a handful of people in Thailand each year.

What is a huge headache for other parts of the world is merely a nagging pain for the Thai medical system.

"We are mostly concerned with injuries caused by accidents and cancer here," Somchai Wititanan, director of Sai Yok's hospital, says with a wry smile. "Malaria is not a scary disease because if you get the treatment, you survive."

In the last year, he says 200 malaria cases have been admitted to his hospital, with 12 showing signs of drug resistance.

All were sent to Bangkok, where a second line of treatment usually involving quinine administered intravenously proved effective.

'Massive crisis'

The nightmare scenario, however, is a repeat of what took place in the 1980s, with what was then the most commonly used anti-malarial drug, chloroquine.

Resistance to chloroquine emerged in South East Asia, spread, and when it reached Africa, the number of malaria cases rose sharply.

Estimates for the number who died vary widely, but in many of the areas surveyed, the number of child fatalities from malaria more than doubled.

The focus now is on trying to monitor and contain artemisinin drug resistance into a few hotspots, prolonging the drug's effective lifespan globally until alternative treatments are available. Africa's hopes of maintaining its progress rests firmly on South East Asia's efforts.

"In Africa [if resistance spreads], we'd see more cases and we'd see more deaths," says Dr Fatoumata Nafo-Traore, former health minister of Mali, and now executive director of Roll Back Malaria, an alliance of global groups.

"We have a highly effective drug to treat malaria and we need to protect it because there is no new drug available on the market."

Resistance to artemisinin-based drugs reaching Africa would be a "massive crisis", she said.

The success at containing the spread of the resistance may depend on what is taking place in Burma.

It has the most malaria cases in Asia, and with the healthcare system threadbare, it is ill-equipped to introduce systems for monitoring and containment. Burma's highly mobile migrant population may already be spreading the drug-resistant strain around the world.

"Our country is the gateway for this kind of drug-resistant malaria to spread west to Bangladesh and India," Saw Lwin, from Burma's Health Ministry, told reporters in Thailand.

"If we cannot contain it at the source, this is a global threat."

The earliest new drugs are likely to be available is 2015, with considerable excitement surrounding the possible development of malaria vaccines.

For now, in the rural clinics of Thailand, Cambodia and Burma, health workers are fighting to defend one of the pillars that support a global success story.

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