Who continues to stock oral artemisinin monotherapy? Results of a provider survey in Myanmar

Abstract

BackgroundArtemisinin-based combination therapy (ACT) is a key strategy for global malaria elimination efforts. However, the development of artemisinin-resistant malaria parasites threatens progress and continued usage of oral artemisinin monotherapies (AMT) predisposes the selection of drug resistant strains. This is particularly a problem along the Myanmar/Thailand border. The artemisinin monotherapy replacement programme (AMTR) was established in 2012 to remove oral AMT from stocks in Myanmar, specifically by replacing oral AMT with quality-assured ACT and conducting behavioural change communication activities to the outlets dispensing anti-malarial medications. This study attempts to quantify the characteristics of outlet providers who continue to stock oral AMT despite these concerted efforts.MethodsA cross-sectional survey of all types of private sector outlets that were stocking anti-malarial drugs in 13 townships of Eastern Myanmar was implemented from July to August 2014. A total of 573 outlets were included. Bivariate and multivariable logistic regressions were conducted to assess outlet and provider-level characteristics associated with stocking oral AMT.ResultsIn total, 2939 outlets in Eastern Myanmar were screened for presence of any anti-malarial drugs in August 2014. The study found that 573 (19.5 %) had some kind of oral anti-malarial drug in stock at the time of survey and among them, 96 (16.8 %) stocked oral AMT. In bivariate analyses, compared to health care facilities, itinerant drug vendors, retailers and health workers were less likely to stock oral AMT (33.3 vs 12.9, 10.0, 8.1 %, OR = 0.30, 0.22, 0.18, respectively). Providers who cut blister pack or sell partial courses (40.6 vs 11.7 %, OR 5.18, CI 3.18–8.44) and those who based their stock decision on consumer demand (32.8 vs 12.1 %, OR 3.54, CI 2.21–5.63) were more likely to stock oAMT. Multivariate logistic regressions produced similar significant associations.ConclusionPrivate healthcare facilities and drug shops and providers who prioritize consumers’ demand instead of recommended practices were more likely to stock oral AMT. Malaria elimination strategies should include targeted interventions to effectively reach those outlets.

Prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency among malaria patients in Upper Myanmar

“…When including P. vivax mixed infection cases, P. falciparum infection rate in individuals with G6PD variants was 66.0% (33/50) while P. falciparum infection rate in those with non-G6PD variants was 59.4% (120/202). This result is consistent with a previous report showing that G6PD deficiency may not effectively protect patients against P. falciparum infection [ 26 ]. Interestingly, no significant association was observed between gender and G6PD variant status in patients with malaria.…”

“…G6PD deficiency is an X-linked hereditary disease. Therefore, males are usually affected more frequently than females as males only have one X-chromosome [ 26 , 27 ]. It has been proposed that G6PD variants render males substantial protection against severe malaria [ 15 ].…”

Human and Simian Malaria in the Greater Mekong Subregion and Challenges for Elimination

“…The threat posed to regional and global malaria control and elimination efforts by artemisinin resistant P. falciparum parasites is imminent and potentially severe. In many Asian countries, operational feasibility of P. vivax elimination is lower than that for P. falciparum [27]. Therefore, creating a viable strategy to achieve vivax elimination goals should include improvements in access to safe treatment to 8-aminoquinoline drugs based radical cure together with improved access to adequate G6PD testing in P. vivax endemic countries.…”

“…One important factor is thought to be the use of oral artemisinin monotherapy (AMT) in place of WHO-recommended ACTs (as unregulated artemisinin or artesunate monotherapy has been available since mid-1970s in the region). In Myanmar, private healthcare facilities and healthcare providers who prioritize consumers' demand instead of recommended practices were more likely to stock oral AMT [26,27]. Malaria elimination strategies should include targeted interventions to effectively reach these outlets.…”

Health education through mass media announcements by loudspeakers about malaria care: prevention and practice among people living in a malaria endemic area of northern Myanmar

“…television, radio, and health education videos) potentially from neighbouring villages [36]. In Myanmar, a project has been broadcasting malaria diagnosis and treatment information since 2017 [37]. In addition, though buffer zones existing between control and treatment village should prevent from message contamination, it cannot be completely excluded due to reasons such as relative-visiting activities between control and intervention villages.…”