Drug-Resistant Malaria

Amazon Malaria Initiative

The past decade has witnessed a steady increase in malaria among the countries of the Amazon Basin region (Bolivia, Brazil, Colombia, Ecuador, Guyana, French Guyana, Peru, Suriname and Venezuela), including the appearance of Plasmodium Falciparum and resistance to inexpensive, first-line anti-malarial drugs. During 2000, P. Falciparum accounted for anywhere from 8% (Bolivia) to 88% (Ecuador) of total cases in the countries of the sub-region. P. Falciparum resistance to chloroquine (the first-line treatment) is common and treatment failure rates of 20% have been reported in some areas of the Amazon. Furthermore, sulfadoxine pyramethamine (a second-line antimalarial drug) resistance has been reported in Colombia, Peru, and Venezuela.

There is little control over population migration between countries in the Amazon region, and vectors do not respect borders. Thus, ineffective control and treatment in one country has an impact on the malaria problem in neighboring countries. To address this issue, the USAID Latin America and Caribbean Bureau, Office of Regional Sustainable Development (LAC/RSD) developed and launched the Amazon Malaria Initiative (AMI) in 2001. By directing resources using a common conceptual framework to selected and coordinated activities in priority countries, the initiative is intended to improve malaria control at the sub-regional level and contribute to decreased morbidity and mortality at the national level. This five-year Initiative complements the ongoing USAID mission bilateral programs and has a budget of approximately $2 million per year. AMI also complements efforts of Roll Back Malaria (RBM) that is coordinated by PAHO and was launched in the nine Amazon countries in 1999.

The objective of AMI is "Malaria control programs in the Amazon Basin sub-region substantially incorporate selected best practices." The anticipated results are as follows: (1) Reliable and standardized surveillance information on malaria drug resistance will be available and used to monitor trends and to more effectively target disease control efforts; (2) Malaria treatment policies based on reliable drug efficacy data will be adopted and implemented; (3) Tools and approaches such as rapid diagnostics and bednets will be adapted, tested in local settings, and disseminated; and (4) Partnerships to improve malaria control will be enhanced. The AMI includes eight target countries: Bolivia, Brazil, Colombia, Ecuador, Guyana, Peru, Suriname and Venezuela. Technical assistance is being provided by the Pan American Health Organization (PAHO), the U.S. Centers for Disease Control and Prevention (CDC), the Rational Pharmaceutical Management (RPMplus) program and the U.S. Pharmacopeia Drug Quality and Information (USPDQI) program. In addition, USAID mission bilateral programs in Peru and Bolivia are assisting with coordination of activities in their respective countries.

During the last three years considerable progress has been made in assessing the geographic distribution and intensity of resistance to first- and second-line antimalarial drugs in the eight target countries making up the Initiative. Three countries, Peru, Bolivia, and Suriname, have already changed their first-line drug regimens to artemisinin-based combination therapy (ACT), as is recommended by the World Health Organization and RBM. These countries are now in the process of evaluating the effectiveness of their new therapies, including aspects such as health worker training, patient acceptance and adherence to the regimens, and adverse drug reactions and in setting up mechanisms for ongoing monitoring of the efficacy of the new regimens. Ecuador, Guyana, and Venezuela have also changed from chloroquine to more efficacious transitional regimens and are currently evaluating the efficacy of different ACT regimens prior to further planned changes in their policies. With these changes to more efficacious but also more expensive antimalarial drugs, drug quality has become an increasingly important issue, and USPDQI is providing training to ministries of health on assessing antimalarial drug quality.

Over the course of the AMI project, and with strong support from PAHO, an excellent network of south-south collaboration has developed, as countries that are further along the continuum of drug efficacy testing and policy change provide training and technical assistance to their neighbors. Although not formally a member of AMI, French Guyana (Department of Guyane Francaise) participates in the regular AMI meetings and is invited to training workshops, as a means of ensuring greater uniformity in malaria treatment policies throughout the region. Proposed AMI activities for the future include evaluations of the importance of malaria in pregnancy in the Amazon region, improving malaria diagnosis with the use of rapid diagnostic tests, and increasing emphasis on malaria vector biology and control.