Insights into the availability and distribution of oral artemisinin monotherapy in Myanmar: evidence from a nationally representative outlet survey

Abstract

BackgroundThe containment of artemisinin resistance in Myanmar, historically an important probable origin and route of anti-malarial resistance to the India sub-continent and beyond, is crucial to global malaria control and elimination. This paper describes what is currently known about the sale and distribution of oral artemisinin monotherapy (AMT) across Myanmar, where this medicine is commonly found.MethodsA nationally representative 2015 outlet survey was conducted in the private sector, and among community health workers across four geographical domains. A national sample of outlets was screened for availability of malaria testing and treatment, and an audit was completed for all anti-malarials.ResultsA total of 3859 outlets across Myanmar had an anti-malarial in stock on the day of survey. Of the 3859 anti-malarial stocking outlets, 988 outlets stocked oral AMT. Availability of oral AMT was highest among outlets in the Western border (36.8%) versus other domains (Eastern, 15.0%; Central, 19.3% Coastal, 10.7%). Over 90% of the oral AMT service delivery points were private sector outlets: general retailers (49.4%), pharmacies (23.5%), and itinerant drug vendors (14.2%). Eleven unique oral AMT products were audited. The most common product audited was Artesunate®, manufactured by Mediplantex in Vietnam, which accounted for 79.9% of the oral AMT market share. Other oral AMT products were manufactured in China and in Myanmar. Over 60% of oral AMT products had a shelf life at purchase of greater than 2 years and only 14.7% were expired. The median number of oral AMT tablets typically dispensed to treat malaria was two tablets, approximately one tenth of a full adult course. The median price of a 50 mg tablet was $0.16.ConclusionsGiven the high availability and distribution of oral AMT, it is possible that Myanmar has become the last remaining viable market for any oral AMT in the region for manufacturers. National and international organizations need to act quickly and effectively to stop the production and distribution to both improve malaria control within Myanmar and reduce risk of artemisinin resistance spreading to India and Africa.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-017-1793-0) contains supplementary material, which is available to authorized users.

When it just won’t go away: oral artemisinin monotherapy in Nigeria, threatening lives, threatening progress

“…In contrast to other research which has shown that the distribution of oral AMT within a country is dominated by the presence of a single manufacturer and product on the market [ 7 ], this study found a diverse oral AMT market in Nigeria. Oral AMT products on the market in 2015 included 11 unique brands from six manufacturers and were imported from Vietnam, China and India.…”

“…Results from ACTwatch outlet surveys have shown that within a few years of the WHO recommendation, oral AMT was no longer available to consumers in multiple malaria endemic countries [ 3 , 4 ]. The exception is ongoing availability and distribution in Nigeria, as described further in this paper, as well as in Myanmar, where oral AMT continues to be available and distributed despite the country’s national policy which has banned the use and importation of this anti-malarial [ 5 – 7 ].…”

Malaria burden and treatment targets in Kachin Special Region II, Myanmar from 2008 to 2016: A retrospective analysis

“…The private sector outlets distributed the oral AMT. The median number of oral AMT tablets was two tablets (about one tenth of a full adult dosage) [ 29 ]. P .…”

Quality Testing of Artemisinin-Based Antimalarial Drugs in Myanmar

“…Similarly, recent surveys of representative outlets in Myanmar have identified that > 25% of drug outlets still stocked oral artemisinin monotherapies. 13 A recent survey in Lao PDR also identified the presence of oral monotherapies of ACAs, 9 but this problem appeared to have resolved lately with tightened governmental regulations. 8 In addition, this survey also found that at least 8% of the drug samples had expired when purchased.…”

“…10,11 Despite these efforts, the recent cross-sectional surveys from the ACTwatch project still detected that oral artemisinin monotherapies were available in close to 20% of private-sector drug outlets. 12,13 Besides, the quality of the ACAs was generally not tested. Therefore, increased surveillance and coordinated regulatory efforts are urgently needed.…”