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Frontline malaria drugs: Effective for how long?

Drug resistance in diseases such as malaria looms as one of the greatest threats to public health of the modern age – frustrating progress against a range of infectious diseases. 

Malaria is considered one of the deadliest mosquito borne diseases in India.

In India, as with many other nations, infectious diseases have been supplanted by noncommunicable conditions as the country’s most common causes of illness and death. However, communicable diseases continue to be pressing concerns. While disease rates have fallen in recent years, many conditions remain widespread whilst others show signs of resurgence. Drug resistance threatens to exacerbate the issue.

A recent Lancet study reveals that the scale of the drug resistance issue is both extensive and encroaching rapidly. The epicentre of a large-scale antimalarial resistance surge exists within southeast Asia, creating a very real concern that malaria in India could soon be significantly more difficult to treat. 

The study shows that, by the 2016–18 period, malaria parasites resistant to frontline therapy artemisinin and its widely used partner drug piperaquine represented more than eighty percent of the parasites present in northeast Thailand and Vietnam, despite having only emerged in western Cambodia in 2008. “These worrying findings indicate that the problem of multidrug resistance in P falciparum has substantially worsened in southeast Asia since 2015,” says Professor Olivo Miotto from the Wellcome Sanger Institute and University of Oxford, UK who co-led the genomic epidemiology study. 

“This highly successful resistant parasite strain is capable of invading new territories and acquiring new genetic properties, raising the terrifying prospect that it could spread to Africa where most malaria cases occur, as resistance to chloroquine did in the 1980s, contributing to millions of deaths.”

The spreading of these antimalarial resistant cases to India also presents a considerable issue due to the sheer size of the population exposed to the risk of contracting malaria. According to the World Malaria Report 2017, more than half of the Indian population (698 million) was at risk of malaria in 2016. The Report estimates there to be a total of 1.31 million malaria cases in the country, with around 23,990 deaths associated with the disease.

The disease burden may actually be far higher according to the estimates of a sixteen-member committee set up by the National Vector Borne Disease Control Programme (NVBDCP). Their estimates place the total annual number of cases in India at about 9.7 million, with between 30,014 and 48,660 deaths.

The United Nations (UN) have recently published a report claiming India’s progress against diseases such as malaria is “dismal”. The reasons for this are the current stagnation of progress against the disease. Though over the last few decades the reduction in disease cases has been significant, the overall rate of decline has stalled considerably in recent years. This has led some to speculate that progress against malaria — as well as other diseases such as tuberculosis that are also seeing a decline in the rate of disease reduction — may even begin to reverse at some point in the near future.

Such an eventuality could easily be brought about by the rapid rise of antimalarial resistant strains. Should frontline therapies become obsolete this would create a further reliance on the often more expensive second line therapies, a situation which could create a number of issues.

India would need to mount a significant increase in healthcare expenditure to fund the use of second-line therapies to prevent drug resistant strains from spiralling out of control. As the country’s healthcare budget remains in its malnourished state, this is a financial toll that may need to be diverted from other healthcare programmes.

In addition to the financing, supply chains would need to be established. While frontline medications are far more commonly available, second-line therapies are often in limited supply, particularly in many of India’s geographically isolated rural communities — many of which may have no stock at all.

As the data from the study shows, the onset of the resistant strains is rapid. Given the prevalence of international travel and other means of transmission, it is not a possibility that drug resistance becomes the norm in India, but when. If India is to avert a coming catastrophe, preparations will need to be made.


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