Availability and quality of anti-malarials among private sector outlets in Myanmar in 2012: results from a large, community-based, cross-sectional survey before a large-scale intervention.

Hnin Su Su Khin,Tin Aung,Ingrid Chen,Dominic Montagu,Willi Mcfarland,May Sudhinaraset,Megan Littrell,Chris White

doi:10.1186/s12936-015-0778-0

Abstract

BackgroundGlobal malaria control efforts are threatened by the spread and emergence of artemisinin-resistant Plasmodium falciparum parasites. In 2012, the widespread sale of partial courses of artemisinin-based monotherapy was suspected to take place in the highly accessed, weakly regulated private sector in Myanmar, posing potentially major threats to drug resistance. This study investigated the presence of artemisinin-based monotherapies in the Myanmar private sector, particularly as partial courses of therapy, to inform the targeting of future interventions to stop artemisinin resistance.MethodsA large cross-sectional survey comprised of a screening questionnaire was conducted across 26 townships in Myanmar between March and May, 2012. For outlets that stocked anti-malarials at the time of survey, a stock audit was conducted, and for outlets that stocked anti-malarials within 3 months of the survey, a provider survey was conducted.ResultsA total of 3,658 outlets were screened, 83% were retailers (pharmacies, itinerant drug vendors and general retailers) and 17% were healthcare providers (private facilities and health workers). Of the 3,658 outlets screened, 1,359 outlets (32%) stocked at least one anti-malarial at the time of study. Oral artemisinin-based monotherapy comprised of 33% of self-reported anti-malarials dispensing volumes found. The vast majority of artemisinin-based monotherapy was sold by retailers, where 63% confirmed that they sold partial courses of therapy by cutting blister packets. Very few retailers (5%) had malaria rapid diagnostic tests available, and quality-assured artemisinin-based combination therapy was virtually nonexistent among retailers.ConclusionInformal private pharmacies, itinerant drug vendors and general retailers should be targeted for interventions to improve malaria treatment practices in Myanmar, particularly those that threaten the emergence and spread of artemisinin resistance.

Highlights

Global malaria control efforts are threatened by the spread and emergence of artemisinin-resistant Plasmodium falciparum parasites
The methods used for this study were adapted from the ACTwatch programme [9], which recorded the types of private outlets sampled, outlet locations, availability of various anti-malarials among outlets sampled, provider demographics, and a brief assessment of provider knowledge and practices for malaria treatment
This study was the first to investigate the private sector anti-malarial market in Myanmar on a large scale, examining the availability of anti-malarial drugs and malaria rapid diagnostic tests (RDTs) in private outlets, the types of anti-malarial drugs available in various types of outlets, provider demographics and basic knowledge of types of malaria and treatment guidelines for falciparum malaria, and provider practices pertaining to the cutting of blister packets and/ or the same of partial courses of anti-malarial drugs

Summary

Introduction

Global malaria control efforts are threatened by the spread and emergence of artemisinin-resistant Plasmodium falciparum parasites. In 2012, the widespread sale of partial courses of artemisinin-based monotherapy was suspected to take place in the highly accessed, weakly regulated private sector in Myanmar, posing potentially major threats to drug resistance. In Southeast Asia, drug resistance of Plasmodium falciparum parasites against first-line anti-malarials, the artemisinins, threaten malaria control efforts worldwide. Myanmar accounts for approximately 85% of the reported malaria cases in the Greater Mekong sub-region of Asia [2], and the spread of artemisinin resistance throughout Myanmar would be devastating for the 37 million individuals living in Myanmar’s malariaendemic areas, but for the global fight against malaria. To prevent a global health emergency, all practices that threaten the emergence of P. falciparum parasites must be changed, and all artemisinin-resistant parasites must be contained and eliminated [6, 7]

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