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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

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

slide2

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

malaria drug policy doh administrative order no 129 a mcp doh date august 23 2002
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

basis for changing treatment policy

> 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)

chloroquine cq and sulfadoxine pyrimethamine sp drug profile in selected study sites philippines
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

slide6

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.

slide7

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

malaria drug policy a o 129 a mcp doh
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
malaria drug policy a o 129 a mcp doh9
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
malaria drug policy a o 129 a mcp doh10
Malaria Drug Policy (A.O.129-A) MCP-DOH
  • Coverage:
  • All government (national and local) and private health facilities nationwide
malaria drug policy a o 129 a mcp doh11
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
malaria drug policy a o 129 a mcp doh12
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
components of phil malaria control program drug policy
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)

components of phil malaria control program drug policy14
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

components of phil malaria control program drug policy15
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

components of phil malaria control program drug policy16
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

slide17

> 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

cq sp and coartem efficacy in selected study sites philippines 2001 2004
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

current situation
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

monitoring drug efficacy and post marketing surveillance
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

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