Health professionals attempting to treat patients with malaria are currently facing another complex obstacle in the developing world: the distribution of substandard, falsified and degraded antimalarial medications.

Drugs classified as substandard are medicines that have insufficient amounts of the necessary active ingredient. In order to effectively kill the bacteria and other harmful organisms thriving inside a malaria patient, the full, prescribed dose of the drug needs to be ingested.

When anything less than the full dose is ingested, these organisms not only continue to survive, but also develop a resistance to the drug entirely. This renders current anti-malaria drugs completely ineffective.

“Poor quality antimalarial drugs are very likely to jeopardize the unprecedented progress and investments in control and elimination of malaria made in the past decade,” according to Fogarty scientist, Gaurvika M.L. Nayyar.

Since the early 2000s, the World Health Organization has recommended artemisinin as the first line of treatment for malaria patients, since “artemisinin and its derivatives are powerful medicines known for their ability to swiftly reduce the number of Plasmodium parasites in the blood of patients with malaria.”

Artemisinin is combined with other supplementary drugs in Artemisinin Combination Therapy treatments in order to effectively assist those diagnosed with malaria. However, these substandard drugs are causing an increase in bacterial resistance to artemisinin treatments, rendering the first line of malaria defense utterly useless.

According to a study done by National Public Radio in 2012, “a third of all anti-malarial drugs taken off the shelf in nonrandom surveys in Africa and Asia were absolutely fake. In about 4,000 samples, there was not a drop of active ingredient there.”

The distribution of these partially active medications has recently been classified as a “global pandemic” affecting the poorest parts of the world, specifically West Africa and Southeast Asia, where drug regulatory systems are weak.

The Centers for Disease Control and Prevention said, “Counterfeiting occurs throughout the world, but it is most common in countries where there are few or no rules about making drugs. An estimated 10 percent to 30 percent of medicines sold in developing countries are counterfeit. In the industrialized world (countries such as the United States, Australia, Japan, Canada, New Zealand, and those in the European Union), estimates suggest that less than one percent of medicines sold are counterfeit.”

On April 20, The American Journal of Tropical Medicine and Hygiene released a special issue, titled “The Global Pandemic of Falsified Medicines: Laboratory and Field Innovations and Policy Perspectives,” which contained a series of 17 papers. Each is written by a different author from a different university or institution, yet all cover the implications surrounding the distribution of substandard medicines throughout the developing world.

According to one of the studies, over 122,350 child deaths were caused by insufficient or partially-active anti-malaria drugs in 2013 alone. This figure represents one-fifth of all deaths caused by malaria.

“These findings are a wake-up call demanding a series of interventions to better define and eliminate both criminal production and poor manufacturing of antimalarial drugs,” Nayyar said.

– Hanna Darroll

Photo: TheraBreath

The threat of antibiotic resistance is once again in the spotlight. Professor Jeremy Farrar, the new head of Britain’s biggest medical research charity warns again of the dangers of antibiotic abuse.

Reports from Chicago are showing the effects of Farrar’s warnings. The largest outbreak of a very specific and very dangerous bacterium in the U.S. has been linked to a procedure performed at a north suburban hospital last year. 44 cases of a strain of bacteria called “carbapenem-resistant enterobacteriaceae” or CRE were identified by the Center for Disease Control (CDC) and Prevention.

The main problem with resistant bugs is their high transmission. Alex Kallen, an infectious diseases doctor who served as the supervisor of the CDC investigation, has stated that most of the patients screened had the bacteria in their digestive track, but not the disease.

The most common infection the bacteria causes is a urinatry tract infection, but if that infection gets to the bloodstream, the patient has a 40 to 50 percent chance of dying, making the bug extraordinarily dangerous.

Simple bugs that reside in the stomach like E. coli and Klebsiella, now require carbapenems, a powerful antibiotic, often used as a last resort, to be treated. In South Africa, an extraordinarily powerful strain of tuberculosis that is virtually untreatable has been popping up around the world. Called XDR-TB, it requires eight different medicines a day, including a shot, and tens of thousands of dollars to treat.

Many individuals who are exposed to these diseases do not have the means to be treated, and as a result, usually are resigned to a bleak fate. However, Professor Greg Hussey of the Institute of Infectious Diseases and Molecular Medicine at UCT believes that the key is in immunization.

“The only solution to defeating TB is to prevent the disease from occurring,” He said. “As with any infectious disease, effective vaccines are of critical importance.”

Professor Farrar has called for the industry to be given incentives to work on antibiotics and research on infectious diseases and greater restrictions placed on access to these medicines.

Professor Dame Sally Davies who, described antibiotic resistance as a “ticking time bomb,” has argued that in up to 20 years, routine operations could become deadly if people lose the ability to fight infection. This will pose exceptionally large problems for cancer treatments or organ transplants where patients are exceptionally susceptible to infections.

“If we don’t take action, then we may all be back in an almost 19th century environment.” Dame Sally said.

Pharmaceutical companies, she said, are discouraged to develop new drugs because the manufacture of antibiotics is not viewed as profitable. Antibiotics usually are only used for a week or two when they’re needed, and even then, they have a limited life span because of the development of resistance. However, drugs for high blood pressure or diabetes, for example, which patients use every day, have much larger markets and therefore receive more funding.

Dr. Ibrahim Hassan, a consultant microbiologist at Wythenshawe Hospital in Manchester, said there are more cases of patients with bacterial infections resistant to antibiotics. Meaning fewer treatment options and higher risk factors.

Dame Sally urges politicians to treat the threat as seriously as the superbug MRSA, an antibiotic resistant form of the common staph infection. She also blames the overuse in animal husbandry, agriculture and fish farming for the current antibiotic epidemic.

The problem arises because while no new classes of antibiotics have been introduced since 1987, new pathogens have been emerging every year. The Chief Medical Officer said antimicrobial resistance was to be put on the government’s national risk register of civil emergencies, which provides guidance for things such as terrorist attacks, pandemic flu and major flooding.

Chloe Nevitt
Feature Writer

Sources: BBC News Health, BBC News, BBC, CBS Chicago, The Wall Street Journal
Photo: The Guardian