Antimalarial drug resistance - Who is to blame?

Malaria treatment failure can arise either due to true antimalarial drug resistance or due to failure to clear malarial parasites from the circulation. The latter is due to incorrect dosing, non-compliance with the duration of dosing, poor drug quality , drug interactions, poor or erratic absorption and misdiagnosis. (Sosa, 2010)

The problem of misdiagnosis is essentially one of overdiagnosis. In many endemic countries, many febrile cases are prescribed antimalarial medication. A prospective observational study conducted in Afghanistan noted that 99% of the bloodsmear-negative patients received antimalarial medication when the diagnosis was based solely on clinical diagnosis. But even when blood smears were used for diagnosis, 50% of smear-negative patients received the medication. (Leslie, 2012). Many patients were thus unnecessarily exposed to the drugs and if they had had low parasitemia, there would have been enough selection pressure to cause drug resistance development.

Unregulated dispensing of drugs is another common problem and is frequently associated with the self-medication. In many developing countries, prescription medication can commonly be purchased over the counter. These include antibiotics and antimalarial drugs. Although there are laws to prevent such practices, these are almost always ignored. The ethics of pharmaceutical personnel are also questionable in these cases and may arise out of sheer ignorance of both pharmaceutical ethics and sound science.

 (Dernavich)

Poverty driven practices are explored in the paper by Planta, M. , titled "The role of poverty in Antimicrobial resistance" , published in the Journal of American Board of Family Medicine, in Nov 2007. The author compares the practices in developing and developed nations. Noncompliance takes different forms in these cohorts, with the factors in developing countries being inadequate access to effective drugs, unregulated manufacture and dispensation of antimicrobials and lack of money to pay for appropriate, high quality medication. In contrast, the practices in developed countries mainly are sharing of antimicrobials and self medication using leftovers from unfinished drug regimens . (Planta MB, 2007). This was also explored at length in the reading for the day (McNulty,2007). Although both the articles explored antibacterial resistance, the same principles apply to sociology of antimalarial resistance.

Other factors that affect drug compliance include age, sex, martial status,educational level, ability to read and household monthly income. A demographical study of arteminisin combination therapy compliance conducted in rural Kenya revealed that only upto 47% of all malaria patients adhered to therapy, in terms of duration and dosage. Of these, 58% were <13 years of age. Adherence was higher among females (55.7%) than males (50.3%). Underaged patients (children) were the most adherent (57.1%), when compared to the married (21.4%), widowed (7.9%), single (2.9%), and separated (0.7%).  (Onyango EO,2012) . This was probably because of higher concern among parents when the children are affected. Busyness and forgetfulness may be contributing factors among the older age groups, because no one intentionally wants to die of malaria, when they have access to medicines.Curiously, adherence increased as household size increased , with households with >6 people being more compliant than others. Undoubtedly, the statistics from this study cannot be extrapolated to wide regions across the globe. But, it gives a glimpse of the various factors that ought to be addressed when policies are laid down to overcome antimalarial resistance.

Increasing the awareness of people everywhere to antimicrobial resistance is an essential next step. Targeted education, information and communication activities are the need of the hour to reduce the risk of contributing to antimalarial resistance. Extension strategies used for doctors and health care workers, pharmaceutical personnel, policy makers and ordinary people residing in endemic areas must be specially designed to adequately cater to each group. Together, we can achieve our goal of overcoming antimalarial resistance.

References :

Leslie T, Mikhail A, Mayan I, et al. Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study. BMJ 2012;345:e4389.

Sosa AbdJ. Antimicrobial resistance in developing countries. New York: Springer, 2010.

Planta MB. The role of poverty in antimicrobial resistance. J Am Board Fam Med 2007;20:533-539.

McNulty CA, Boyle P, Nichols T, et al. The public's attitudes to and compliance with antibiotics. J Antimicrob Chemother 2007;60 Suppl 1:i63-68

Onyango EO, Ayodo G, Watsierah CA, et al. Factors associated with non-adherence to Artemisinin-based combination therapy (ACT) to malaria in a rural population from holoendemic region of western Kenya.BMC Infect Dis 2012;12:143.

Cartoons :

Dernavich, D. http://www.condenaststore.com/-sp/Woman-looking-at-pharmacy-shelves-labelled-Classics-Best-Sellers-and-New-Yorker-Cartoon-Prints_i8479870_.htm

Glasbergen, R. http://www.glasbergen.com/pharmacy-cartoons/