The efficacy of amodiaquine (AQ) and sulfadoxine-pyrimethamine (SP) was assessed in 310 symptomatic children from western Kenya with uncomplicated Plasmodium falciparum malaria. A non-blinded, randomized, 14-day study was performed and parasitologic criteria were used. Of 310 patients included, 238 (77%) completed the study: 120 received AQ and 118 received SP. In those treated with AQ, there were sensitive (S) infections in 107 patients (89.2%, 95% confidence interval [CI] = 82.2, 94.1%), RI resistance in 10 (8.3%, 95% CI = 4.1, 14.8%), RII resistance in 1 (0.8%, 95% CI = 0, 4.6%), and RIII resistance in 2 (1.7%, 95% CI = 0.2, 5.9%). In those treated with SP, there were S infections in 74 patients (62.7%, 95% CI = 53.3, 71.4%), RI resistance in 21 (17.8%, 95% CI = 11.4, 25.9%), RII resistance in 11 (9.3%, 95% CI = 4.7, 16.1%), and RIII resistance in 12 (10.2%, 95% CI = 5.4, 17.1%). Resistance rates were consistently higher in the SP-treated patients (P < 0.001). Resistance to SP in this area has reached such levels that it should no longer be the first-line treatment. Alternative treatment, such as SP plus AQ combination treatment or artemisinin combination treatment, is urgently needed.
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"AL has been the recommended first line treatment for uncomplicated malaria in Kenya since 2006. SP is still widely available and used, but resistance is common; more than 80% of infections are resistant  resulting in 22-40% treatment failure [21,22]. Forty-four percent of malaria medicine retailers had AL in stock on the day of the survey, and an additional 20% reported stocking it but were out of stock that day. "
[Show abstract][Hide abstract] ABSTRACT: Poor access to prompt and effective treatment for malaria contributes to high mortality and severe morbidity. In Kenya, it is estimated that only 12% of children receive anti-malarials for their fever within 24 hours. The first point of care for many fevers is a local medicine retailer, such as a pharmacy or chemist. The role of the medicine retailer as an important distribution point for malaria medicines has been recognized and several different strategies have been used to improve the services that these retailers provide. Despite these efforts, many mothers still purchase ineffective drugs because they are less expensive than effective artemisinin combination therapy (ACT). One strategy that is being piloted in several countries is an international subsidy targeted at anti-malarials supplied through the retail sector. The goal of this strategy is to make ACT as affordable as ineffective alternatives. The programme, called the Affordable Medicines Facility - malaria was rolled out in Kenya in August 2010.
In December 2010, the affordability and accessibility of malaria medicines in a rural district in Kenya were evaluated using a complete census of all public and private facilities, chemists, pharmacists, and other malaria medicine retailers within the Webuye Demographic Surveillance Area. Availability, types, and prices of anti-malarials were assessed. There are 13 public or mission facilities and 97 medicine retailers (registered and unregistered).
The average distance from a home to the nearest public health facility is 2 km, but the average distance to the nearest medicine retailer is half that. Quinine is the most frequently stocked anti-malarial (61% of retailers). More medicine retailers stocked sulphadoxine-pyramethamine (SP; 57%) than ACT (44%). Eleven percent of retailers stocked AMFm subsidized artemether-lumefantrine (AL). No retailers had chloroquine in stock and only five were selling artemisinin monotherapy. The mean price of any brand of AL, the recommended first-line drug in Kenya, was $2.7 USD. Brands purchased under the AMFm programme cost 40% less than non-AMFm brands. Artemisinin monotherapies cost on average more than twice as much as AMFm-brand AL. SP cost only $0.5, a fraction of the price of ACT.
AMFm-subsidized anti-malarials are considerably less expensive than unsubsidized AL, but the price difference between effective and ineffective therapies is still large.
"Although currently available evidence regarding the efficacy of IPTi with SP is promising , –, the protective efficacy of IPTi with SP in more recent trials has been more modest than the initial Tanzania trial, and a recent study reported no protective efficacy of IPTi with SP . In addition, Plasmodium falciparum resistance to SP is high in sub-Saharan Africa , , and alternative drugs for this strategy need to be identified. The mechanism by which IPTi works is not well understood: it is unknown whether the intermittent clearance of existing malaria infections (treatment effect) or the post-treatment prophylactic effect of long-acting drugs is more important . "
[Show abstract][Hide abstract] ABSTRACT: Intermittent preventive treatment in infants (IPTi) with sulphadoxine-pyrimethamine (SP) for the prevention of malaria has shown promising results in six trials. However, resistance to SP is rising and alternative drug combinations need to be evaluated to better understand the role of treatment versus prophylactic effects.
Between March 2004 and March 2008, in an area of western Kenya with year round malaria transmission with high seasonal intensity and high usage of insecticide-treated nets, we conducted a randomized, double-blind placebo-controlled trial with SP plus 3 days of artesunate (SP-AS3), 3 days of amodiaquine-artesunate (AQ3-AS3), or 3 days of short-acting chlorproguanil-dapsone (CD3) administered at routine expanded programme of immunization visits (10 weeks, 14 weeks and 9 months).
1,365 subjects were included in the analysis. The incidence of first or only episode of clinical malaria during the first year of life (primary endpoint) was 0.98 episodes/person-year in the placebo group, 0.74 in the SP-AS3 group, 0.76 in the AQ3-AS3 group, and 0.82 in the CD3 group. The protective efficacy (PE) and 95% confidence intervals against the primary endpoint were: 25.7% (6.3, 41.1); 25.9% (6.8, 41.0); and 16.3% (-5.2, 33.5) in the SP-AS3, AQ3-AS3, and CD3 groups, respectively. The PEs for moderate-to-severe anaemia were: 27.5% (-6.9, 50.8); 23.1% (-11.9, 47.2); and 11.4% (-28.6, 39.0). The duration of the protective effect remained significant for up to 5 to 8 weeks for SP-AS3 and AQ3-AS3. There was no evidence for a sustained beneficial or rebound effect in the second year of life. All regimens were well tolerated.
These results support the view that IPTi with long-acting regimens provide protection against clinical malaria for up to 8 weeks even in the presence of high ITN coverage, and that the prophylactic rather than the treatment effect of IPTi appears central to its protective efficacy.
"Vector abundance is an important determinant of malaria transmission force (Garrett-Jones 1964) and thus factors that increase or decrease vector abundance will have an impact on prevalence of the disease . Intervention using antimalaria drugs has been used as the primary tool for malaria control; however, increasing drug resistance has weakened this strategic tool (Vreugdenhil et al. 2004, Whitty et al. 2004). "
[Show abstract][Hide abstract] ABSTRACT: Studies were carried out at three sites in the highlands of western Kenya (Iguhu and Mbale in Kakamega and Vihiga districts, respectively, and Marani in Kisii district) and at one site in the western Kenya lowlands (Kombewa in Kisumu district) to determine the spatial-temporal dynamics of malaria vectors and intensity of malaria transmission from June 2003 to June 2004. At the highland sites, Anopheles gambiae Giles predominated, constituting >80% of the vector species, whereas An. funestus Giles made up <20%. In contrast, at the lowland site, An. funestus made up 68% of the vector species. The mean annual indoor resting densities of An. gambiae at Iguhu were 5.0 female mosquitoes per house per night, 14.2- and 26.3-fold greater than those at Mbale and Marani. During the main transmission season, the indoor resting densities of An. gambiae increased 4.1-, 10.1-, and 5.0-fold over the dry season period in Iguhu, Mbale, and Marani, respectively. The estimated annual entomological inoculation rate (EIR) at Iguhu was 16.6 infectious bites per person per year (ib/p/yr), 1.1 at Mbale, and 0.4 at Marani. This suggests high spatial variation in vector abundance and malaria transmission intensity. At the lowland site, Kombewa, the total annual EIR was 31.1 ib/p/yr and the indoor resting densities during the transmission season increased 7.1-fold in An. funestus and 18.5-fold in An. gambiae sensu lato over the dry season. The low level of transmission in the highlands suggests that it may be disrupted by vector control methods such as residual spraying.
Full-text · Article · Apr 2006 · Journal of Medical Entomology