Abstract
BackgroundThe containment of artemisinin resistance in Myanmar, historically an important probable origin and route of anti-malarial resistance to the India sub-continent and beyond, is crucial to global malaria control and elimination. This paper describes what is currently known about the sale and distribution of oral artemisinin monotherapy (AMT) across Myanmar, where this medicine is commonly found.MethodsA nationally representative 2015 outlet survey was conducted in the private sector, and among community health workers across four geographical domains. A national sample of outlets was screened for availability of malaria testing and treatment, and an audit was completed for all anti-malarials.ResultsA total of 3859 outlets across Myanmar had an anti-malarial in stock on the day of survey. Of the 3859 anti-malarial stocking outlets, 988 outlets stocked oral AMT. Availability of oral AMT was highest among outlets in the Western border (36.8%) versus other domains (Eastern, 15.0%; Central, 19.3% Coastal, 10.7%). Over 90% of the oral AMT service delivery points were private sector outlets: general retailers (49.4%), pharmacies (23.5%), and itinerant drug vendors (14.2%). Eleven unique oral AMT products were audited. The most common product audited was Artesunate®, manufactured by Mediplantex in Vietnam, which accounted for 79.9% of the oral AMT market share. Other oral AMT products were manufactured in China and in Myanmar. Over 60% of oral AMT products had a shelf life at purchase of greater than 2 years and only 14.7% were expired. The median number of oral AMT tablets typically dispensed to treat malaria was two tablets, approximately one tenth of a full adult course. The median price of a 50 mg tablet was $0.16.ConclusionsGiven the high availability and distribution of oral AMT, it is possible that Myanmar has become the last remaining viable market for any oral AMT in the region for manufacturers. National and international organizations need to act quickly and effectively to stop the production and distribution to both improve malaria control within Myanmar and reduce risk of artemisinin resistance spreading to India and Africa.
Highlights
The containment of artemisinin resistance in Myanmar, historically an important probable origin and route of anti-malarial resistance to the India sub-continent and beyond, is crucial to global malaria control and elimination
Findings from the project point to the persistent widespread availability and distribution of oral artemisinin monotherapy (AMT) in Myanmar, which accounts for the highest burden of malaria in the Greater Mekong Sub-region (GMS) and is notably considered an important probable origin and route of multi-drug resistance
Oral artemisinin monotherapy was banned in Myanmar in 2012 by the Myanmar Food and Drug Administration (FDA)
Summary
The containment of artemisinin resistance in Myanmar, historically an important probable origin and route of anti-malarial resistance to the India sub-continent and beyond, is crucial to global malaria control and elimination. Recent market intelligence data, generated by the ACTwatch project [5, 6], illustrates that oral AMT continues to be distributed and sold in some countries, in the private sector. Outlet survey trend data from Eastern Myanmar over the years have shown that despite a plethora of strategies to remove this from the market, oral artemisinin monotherapy commonly persists [7]. This has included the Artemisinin Monotherapy Replacement (AMTR) project, which was designed to rapidly remove artemisinin monotherapies from the market by increasing private sector access to first-line subsidized artemisinin-based combination therapy (ACT) medicines. Additional project activities targeted private sector providers (general retailers, pharmacies and itinerant drug vendors) located in Eastern Myanmar to encourage adoption of ACT
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