Abstract
.Artemisinin combination therapy is recommended for the treatment of multidrug resistant Plasmodium falciparum and Plasmodium vivax. In March 2006, antimalarial policy in Indonesia was changed to a unified treatment with dihydroartemisinin-piperaquine for all species of malaria because of the low efficacy of previous drug treatments. In 2013, a randomized cross-sectional household survey in Papua was used to collect data on demographics, parasite positivity, treatment-seeking behavior, diagnosis and treatment of malaria, and household costs. Results were compared with a similar survey undertaken in 2005. A total of 800 households with 4,010 individuals were included in the 2013 survey. The prevalence of malaria parasitemia was 12% (348/2,795). Of the individuals who sought treatment of fever, 67% (66/98) reported attending a public provider at least once compared with 46% (349/764) before policy change (P < 0.001). During the 100 visits to healthcare providers, 95% (95) included a blood test for malaria and 74% (64/86) resulted in the recommended antimalarial for the diagnosed species, the corresponding figures before policy change were 48% (433/894) and 23% (78/336). The proportion of individuals seeking treatment more than once fell from 14% (107/764) before policy change to 2% (2/98) after policy change (P = 0.005). The mean indirect cost per fever episode requiring treatment seeking decreased from US$44.2 in 2005 to US$33.8 in 2013 (P = 0.006). The implementation of a highly effective antimalarial treatment was associated with better adherence of healthcare providers in both the public and private sectors and a reduction in clinical malaria and household costs.
Highlights
In Indonesia, the greatest prevalence of malaria is in the eastern provinces of Nusa Tenggara Timur and Papua.[1]
The median duration that heads of households reported residing at their current location was 13 years (IQR = 6–20), with 23 (3%) households reporting a move into that location within the previous year
One individual (1%) did not seek treatment outside of the home compared with 8% in 2005 when less efficacious treatments were available in both the public and private sectors
Summary
In Indonesia, the greatest prevalence of malaria is in the eastern provinces of Nusa Tenggara Timur and Papua.[1]. 12% of the population still reside in areas with a malaria incidence greater than one case per 1,000 per year,[2] and these individuals are at increased risk of malaria associated anemia.[3,4] Until 2006, the first line policy was chloroquine plus sulfadoxine-pyrimethamine and a single dose of primaquine for uncomplicated Plasmodium falciparum malaria, and chloroquine plus primaquine (total dose 3.5 mg/kg over 14 days) for radical cure for Plasmodium vivax with the exception of infants less than 1 year of age and pregnant or lactating women for whom chloroquine alone was recommended.[5] In 2005, clinical trials in Papua, Indonesia, highlighted very high levels of antimalarial drug resistance to the recommended treatment regimens with recrudescent P. falciparum and recurrent P. vivax infections exceeding 40% by day 28 after treatment.[5,6,7] Dihydroartemisinin-piperaquine (DHP) was shown to be highly effective against both species.[8,9] In response, national policy was changed in March 2006 to the fixed dose artemisinin combination therapy (ACT) of DHP for uncomplicated malaria due to any species of malaria.[8,9] The recommendation of single dose primaquine for P. falciparum remained, whereas the dose of primaquine recommended for P. vivax was increased to a total of 7 mg/kg over 14 days. The policy stipulated that antimalarial treatment should only be given after laboratory confirmation, which was not a recommendation before 2006
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