Drug resistant malaria strain in Myanmar causes alarm

A drug resistant strain of malaria has been detected in Myanmar, just 25 kilometres from the Indian border, a new study published in medical journal Lancet said.

The report published on Friday is heightening concern in medical circles over the possibility of its spread westward towards South Asia and Africa, which could endanger millions. 

It lends more urgency to calls for a sharply enhanced response to the spread of malaria which is resistant to the drug artemisinin, and which has started and spread in the Greater Mekong Subregion (GMS) – Thailand, Cambodia, Laos, Vietnam and Myanmar. 

"Resistance to the antimalarial drug artemisinin is established in Myanmar and has reached within 25km of the Indian border," the report in Lancet Infectious Diseases said. "It appears (it) is following the same historical trajectory from the Thai-Cambodia border across Southeast Asia, as seen in the past with other frontline anti malarial medicines." ‘’The potential spread of artemisinin resistance... into neighbouring India poses a serious threat to the global control and eradication of malaria. If drug resistance spreads from Asia to the African sub-continent, or emerges in Africa independently, as we’ve seen several times before, millions of lives will be at risk of artemisinin treatment failure." The artemisinin resistant parasite was found in Homalin, in Myanmar’s Sagaing region only 25km from the Indian border, by a team led by Dr Kyaw Myo Tun of the Defence Services Medical Research Centre in Naypyitaw, as part of a study coordinated by the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok.  “Myanmar is considered the frontline in the battle against artemisinin resistance as it forms a gateway for resistance to spread to the rest of the world” said Dr Charles Woodrow of the Mahidol-Oxford Tropical Medicine Research Unit, who was senior author of the study. The global community has a rapidly narrowing window to eliminate malaria to stop a global rebound, experts warn.  Drug resistant malaria is not just spreading, but emerging independently in multiple locations across the GMS, raises the spectre of the resistant parasite plunging humanity into a "pre-penicillin era" said Professor Paul Lalvani, New Delhi-based expert in public health and pharmaceuticals.  The Anopheles mosquito-borne parasite accounted for 198 million cases globally in 2013, and an estimated 584,000 deaths, according to the World Health Organisation (WHO). 

Ninety per cent of all malaria deaths were in Africa, where an estimated 437,000 children below the age of five died from it in 2013.  The malaria rate is declining – but the emergence of drug resistant malaria threatens to overturn all the gains.  On the sidelines of a one-day conference of health experts and government officials in Bangkok last Friday, Professor Lalvani, Dean of the Empower School of Health in New Delhi, told The Straits Times: "If it goes from here to Africa where 90 per cent of the deaths are, of which 90 per cent are children, it will be a large scale disaster." At the conference national malaria control programme, officials from six countries all talked about the new goal of elimination by 2030, likely to be backed by financial pledges at the World Health Assembly in May this year.  Malaria has for the past 15 years or so been treated with a combination of drugs with one common factor – artemisinin, derived from a Chinese plant called Qinghaosu. But the emergence of resistance of the malarial plasmodium falciparum parasite to artemisinin in multiple areas is new in the annals of drug resistance. With a new drug at least 5-10 years away, this forced a radical change of strategy.   "Artemisinin was presented as a miracle drug to which resistance would never emerge, so first of all everybody was surprised," Dr Pascal Ringwald, WHO's top malaria expert, told The Straits Times on the sidelines of the conference.    "With all your eggs in one basket, you now face a problem that all the combinations used to treat malaria contain artemisinin, and they are all weakened by the fact of artemisinin resistance."  "We tried containment, to avoid the parasite going outside the region," said Dr Ringwald. "When you reduce the burden of malaria in an area the risk of it spreading is lower." "But if you try and contain a fire here and another fire is starting there, it doesn’t make sense to contain the fire here. So we completely changed our minds. This needs a completely different strategy on how to tackle the problem." The total cost of eliminating Malaria in the GMS - Thailand, Laos, Myanmar, Vietnam, Cambodia and Yunnan in China - would range from USD 3.2 to 3.9 billion (S$4 billion to S$4.88 billion) over 15 years, or an average of US$1.8 to 2.2 per capita for the at risk population, per year, health experts estimate.  Much of this investment - backed up by political commitment - would have to be in strong public health surveillance, case management, good quality drugs as opposed to counterfeit drugs which are also rampant in the region – and interventions such as mosquito control and medicated mosquito nets, Dr. Ringwald said.

nirmal@sph.com.sg