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Anti-Malaria Drug Policy Philippines

Anti-Malaria Drug Policy Philippines. Workshop on Anti-Malarial Drug Policy Implementation Review Wuxi City, Jiangsu Provincial Institute of Parasitic Diseases, P.R. China September 12 – 22, 2005. GEOGRAPHICAL DISTRIBUTION OF MALARIA PHILIPPINES ( Based on 10-year Average, 1991 – 2000 ).

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Anti-Malaria Drug Policy Philippines

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  1. Anti-Malaria Drug PolicyPhilippines Workshop on Anti-Malarial Drug Policy Implementation Review Wuxi City, Jiangsu Provincial Institute of Parasitic Diseases, P.R. China September 12 – 22, 2005

  2. GEOGRAPHICAL DISTRIBUTION OF MALARIA PHILIPPINES ( Based on 10-year Average, 1991 – 2000 ) • Category A Provinces • 25 Provinces • more than 1000 cases/year or • situation worsened • Category B Provinces • 22 Provinces • 100 to < 1000 cases/year or • situation has improved in the last 5 yrs • Category C Provinces • 18 Provinces • less than 100 cases/year • Category D Provinces • 13 provinces • Malaria-free (no more indigenous cases for at least 3 years Source: Malaria Control Program, 2000 Department of Health

  3. Malaria Drug Policy (DOH Administrative Order No.129-A) MCP-DOHDate: August 23, 2002 “Previous” Drug Policy 1st line: Chloroquine 2nd line: Sulfadoxine-Pyrimethamine (SP) 3rd line: Quinine + Primaquine New Drug Policy 1st line: CQ+SP 2nd line: Artemether + lumefantrine [Coartem™ ] 3rd line: Quinine + anti- biotic (Tetracycline, clinda, doxy, erythro) + Primaquine

  4. > 25% 16 - 24% 6- 15% < 5% Basis for Changing treatment policy DRUG TREATMENT FAILURE RATES in the Philippines, 2000 Treatment Failure Rate CQ >>> 25% SP > 25% (MCS, 1996-1997; Preliminary Report ENHR, 2000; ADS-MCP, 1997-2000; WHO-RBM, 2000-2001)

  5. Chloroquine (CQ) and Sulfadoxine-Pyrimethamine (SP) Drug Profile in Selected Study Sites, Philippines • Kal-Apayao (2000) CQ > 42% Tx F SP > 9% Tx F • Palawan (1994-2000) • CQ 39-76% Tx F • SP 12.5-20% TxF • Davao N-ComVal (2000) • Agusan del Sur (97-01) CQ > 50% Tx F SP > 43% Tx F

  6. This high treatment failure rates provide a very strong evidence for the DOH to immediately review & change existing anti-malarial drug policy in the country.Combination therapy becomes a more viable alternative in improving efficacy of available drugs.

  7. Combination CQ+SP vs Coartem™ , Agusan del Sur and Compostela Valley, Philippines, 2001 - therapeutic efficacy surveillance done in small population to predict outcome of treatment in known drug resistant areas Study Site Drugs N 28-day Tx F Cure Rate ADS CQ+SP 39 36 4 89% (32/36) SP 35 32 17 47% (15/35) Laac, CV CQ+SP 40 38 7 82% (31/38) Coartem 40 36 0 100% Espino et al, 2001. Preliminary report, WHO/RBM-ADS/MCP

  8. Malaria Drug Policy (A.O.129-A) MCP-DOH • 100% efficacy of A-L combination, however restricted to be used as 2nd line drug bec. of: • limited findings of its safety for very young children, pregnant women & breastfeeding mothers. • Inadequate capability of the current health infrastructure in many endemic areas to provide confirmatory diagnosis. • DOH: more time to explore & further study the use of artemisinin-based combinations before it is adopted as 1st line drug

  9. Malaria Drug Policy (A.O.129-A) MCP-DOH • Provides policies & guidelines for diagnosis and combination chemotherapy for malaria • Objective: • Further reduce the development of drug resistance & ultimately towards reducing morbidity & transmission & preventing complications & malaria deaths

  10. Malaria Drug Policy (A.O.129-A) MCP-DOH • Coverage: • All government (national and local) and private health facilities nationwide

  11. Malaria Drug Policy (A.O.129-A) MCP-DOH • Implementation: • To be implemented in phases • Why? • - NMCP to manage the increase in cost of diagnosis & treatment • - Centers for Health Development (15 Regional Health Offices) to strengthen & expand its capacity for implementation

  12. Malaria Drug Policy (A.O.129-A) MCP-DOH • Implementation: • Priority 1: • - Project sites where capacity building for drug policy implementation has already been carried out/underway • - Malaria microscopy centers at the Rural Health Units are already established/upgraded • Priority 2: Category A provinces (GFATM-MC) • Priority 3: Category B provinces • Priority 4: all other endemic provinces

  13. Components of Phil. Malaria Control Program Drug Policy • Anti-malarial drug list according to use & guidelines for drug use - Combination treatment for P. falciparum malaria uncomplicated: 1st line: CQ+SP 2nd line: Artemether-Lumefantrine 3rd line: Quinine + T/D severe: QN + T/D/Clinda + Primaquine (single dose) - Tx for P. vivax malaria (CQ + Prima) - Tx for mixed infection (CQ+SP+Prima) - Tx for pregnant women & children <1 y.o. (QN) - chemoprophylaxis (Doxy/mefloquine)

  14. Components of Phil. Malaria Control Program Drug Policy •Diagnosis (laboratory confirmation – Microscopy/RDT) - QA/AS – microscopy pilot-test - QA/AS – RDT (future plan) • Regulations for treatment & provision of drugs - all probable & confirmed malaria using 1st line – administered by trained field health workers - Tx of P. falciparum & severe/complicated malaria using A-L & QN+T/D – only dispensed by a physician/PHN upon lab. confirmation - supervised Tx (ST) shall be adopted - referral of patients (i.e. indications of severe malaria, pregnant women, children < 5 y.o.) using the existing referral system

  15. Components of Phil. Malaria Control Program Drug Policy - Tx in outbreaks emergency situation: P. falciparum: A-L, + prima (ensure rapid cure w/ lowest risk of Tx failure P. vivax: CQ + prima • Support Systems: - Health Human Resource Dev’t: Re-training of health personnel - Logistics Mgt. System (ensure continuous supply of drugs, lab. supplies, under/over-stocking, drug expiration, etc) a) provision of 1st line drugs & lab. supplies – shared responsibility of DOH-Centers for Health Devt & Local Govt Units b) Sourcing out of funds & provision of 2nd & 3rd line drugs: Central Office, DOH c )Distribution mechanism – to ensure proper allocation & availability of drugs, supplies

  16. Components of Phil. Malaria Control Program Drug Policy - Reporting & Surveillance System • Roles & Responsibilities - Identified roles of the National, Regional, LGU (Provl Health Office, Rural Health Units, Village Health Workers, other volunteers), NGOs • Regulations on QA & monitoring of Tx efficacy - Re-training of all health personnel /institutions - Established sentinel sites to conduct therapeutic efficacy studies

  17. > 25% 16 - 24% 6- 15% < 5% Current Treatment Failure Rate to CQ+SP as first-line drug >15% COARTEM 100% Efficacy DRUG TREATMENT FAILURE RATES, Philippines, 2002

  18. CQ+SP and Coartem™ Efficacy in Selected Study Sites Philippines, 2001-2004 • Kalinga & Isabela 2004 CQ+SP 94% ACPR AL 98-100% • Palawan, 1995 CQ+SP 87%ACPR 2005 on-going TES • Com Val & ADS, 2001 CQ+SP 85% ACPR AL 100% ACPR 2005 on-going TES

  19. Current Situation: First line drug CQ+SP with 85% efficacy in some areas (interim policy until when?) Tasks at Hand: Use drugs wisely to prolong their useful lifespan - Retrain health personnel on new drug policy - Improve diagnosis, improve compliance (ST) - Train hospital-based MDs on case management Monitor drug efficacy at sentinel sites

  20. Monitoring drug efficacy and post-marketing surveillance Treatment response to recommended drugs being monitored in sentinel sites to detect signs of decreasing drug susceptibility  Supervised treatment and laboratory diagnosis needed to avoid misuse of drugs  Post-marketing surveillance to identify problems related to adverse reactions, stability, quality and drug efficacy

  21. Thank you

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