Zambia switches to artemisinin to treat childhood malaria

Incidence of childhood malaria is growing in Africa. This has coincided with increased resistance to first choice antimalarial drugs such as chloroquine.  In December 2002, Zambia became the first country to replace chloroquine with the artemisinin based combination therapy, artemether-lumefantrine for patients weighing 10 kilograms or more.

Artemisinin basedcombination therapy (ACT) is new and relatively expensive but has also provedhighly effective in Africa. A research team led by the KEMRI/Wellcome TrustCollaborative Programme and Boston University, USA, evaluated treatmentpractices for uncomplicated malaria in Zambia following this change of drugpolicy.

The team conducted a survey of 944 childrenwith uncomplicated malaria who attended 94 health facilities across fourdistricts in Zambia: Chingola, an urban district with low or moderate rates ofmalaria infection; Kalomo, a semi-arid area with moderate rates of infection;Chipata, a mixed rural and urban district with moderate and high rates ofinfection; and Samfya, a rural, swampy area with high rates of malariainfection.

The study foundthat artemether-lumefantrine was not commonly used. Although programmeactivities such as in-service training and provision of job aids wereimplemented to some extent this did not seem to influence the prescribing ofartemether-lumefantrine among children weighing 10 kilgrams or more. Resultsshowed that:

• Sulfadoxine-pyrimethamine (SP) was availableat 100 percent of clinics, while chloroquine was available at 76 percent andartemether-lumefantrine at just 51 percent.
• Out of all 944 children surveyed, onlyone child received chloroquine.
• For children weighing less than 10kilograms, health workers commonly prescribed SP in accordance withclinical guidelines.
• Health workers prescribedartemether-lumefantrine to only 11 percent of the children weighing 10kilograms or more, and SP to 68 percent.
• At facilities whereartemether-lumefantrine was available on the day of the survey, healthworkers prescribed it to only 22 percent of children weighing 10 kilogramsor more.
• In-service training onartemether-lumefantrine, presence of artemether-lumefantrine dosage wallcharts, and possession of the guideline were not significantly associatedwith prescribing artemether-lumefantrine.
• There was a significantly lower use ofartemether-lumefantrine among children under two years.

The researchers concludethat Zambia has successfully discontinued the use of chloroquine for treatinguncomplicated malaria. Health workers were also using SP appropriately forchildren weighing less than 10 kilograms. However, many clinics were not usingartemether-lumefantrine appropriately. They conclude that:

• Understanding possible misperceptionsand concerns should be a high research priority for Zambia and othercountries in the process of implementing ACT.
• There is an urgent need for a sustainablesupply of ACT across Africa, however, this must be accompanied by similarinvestments in programme activities to ensure the proper use of drugs atthe point of care.