New Malaria Drug Demands New Standards of Care

The good news: malaria, which kills a million people each year, is effectively treated with a new drug. The bad news: the better treatment is ten times as expensive as the former treatment, and health workers in sub-Saharan Africa who have been accustomed to handing out antimalarial drugs as a precautionary measure must now change their ways — drastically. Enter Davidson Hamer, an associate professor of international health for the School of Public Health’s Center for International Health, whose research is aimed at minimizing the unnecessary use of a treatment that health workers can no longer afford to distribute freely.

In the spring of 2006, Hamer and a group of eight international doctors and researchers spent three months in Zambia, which three years earlier became the first African country to change the national antimalarial treatment policy to the artemisinin-based combination therapy called artemether-lumefantrine. Hamer and the researchers visited health clinics all over the country, asking patients who complained of classic signs of malaria  — headache, fever, chills, and other flu-like symptoms — about the type of treatment they received.

Hamer’s study, which was published in the Journal of American Medical Association in May, found that while 73 percent of health facilities had access to malarial diagnostic equipment, most patients who presented with fever alone were never tested. He also found that two-thirds of those untested patients were given antimalarial medicine. In addition, the clinics often prescribed antimalarial medications to patients who tested negative for the parasite. The problem, according to the World Health Organization, is that resistance to traditional malaria medication is now spreading in all the affected countries, which include nations in East Africa and Southeast Asia.

Hamer’s test results varied with the type of test used for diagnosis. When the test used microscopy, 58.4 percent of patients with a negative diagnosis received antimalarial medication. When clinicians used a rapid antigen-detection diagnostic tests (RDTs), which require blood samples to be mixed with chemicals and tested on a special strip of cellulose, 35.5 percent of patients with a negative diagnosis received treatment. Hamer says he suspects that medical workers may be assuming that a negative blood smear could mean that the parasite is in the body, but hasn’t made its way into the bloodstream yet.

“Ideally,” he says, “you should retest. But this is impractical because people have come a long way to the clinic, so they’ll just treat for malaria. At this point we really don’t know why people are making these choices. That’s something we will hopefully be looking at in future studies.”

In the meantime, Hamer is trying to change the malaria diagnosis and treatment practices of primary health care workers in Zambia and Kenya. One effort involves paying a “small cash bonus” to health care workers who reach certain targets in terms of using the correct drug, dose, and duration of treatment, as documented by a supervisor.

He is also working on a proposal to introduce a text-messaging system in Kenya, a country where more than 85 percent of primary health care workers who treat malaria have mobile phones. With text messaging, he says, messages could be sent several times a day reminding workers of things like proper dosage.

“After the initial training, there aren’t many rounds of retraining, nor are there regular reminders or adequate supervision to reinforce some of the key things primary health care workers need to take away from training,” says Hamer. “By using short text messages, we’re going to try to enhance that.”

Nicole Laskowski can be reached at nicolel@bu.edu.