Despite restriction on antimalarial resistant drugs – they are still used to treat malaria

With about 100 million cases and 300,000 malaria deaths annually, Nigeria has the highest burden of malaria in the world.

The statistics are shocking and are as a result of a number of factors including lack of resources, weak political commitment and a lack of communication and ignorance of the causes and how to prevent malaria, a source who spoke under the condition of anonymity, said.

In 2005, Nigeria phased out the use of chloroquine and a combination of sulfadoxine-pyrimethamine for the treatment for malaria, even though the drug has been found to be an effective intermittent preventive treatment (IPT) for pregnant women.

But investigation showed that the drugs are still in circulation.

At Alausa, Ikeja, all the small chemist stores visited (two of them), recommended chloroquine and sulfadoxine -pyrimethamine (even though chloroquine is a prescription only medicine).

This reporter had expressed worry about the cost of an Artemisinin Combination Therapy (ACT), the recommended treatment for malaria.

If you thought the sale of the non-recommended drugs was limited to dingy chemists, think again, as there is certainly a proliferation of the use of monotherapies for the treatment of malaria in Lagos, where the investigation was conducted.

In four pharmacies, some of them luxurious, visited by this reporter, chloroquine and sulfadoxine-pyrimethamine were sold – over the counter – without a prescription.

“People, especially the older ones, still ask for chloroquine for the treatment of malaria,” a pharmacist said.

When asked the pharmacist knew they were no longer recommended as treatment for malaria in Nigeria and if she asked people what they needed to use the drugs for, she said: “This is a community pharmacy.”

“When people come here and they ask for the drugs, you can’t go questioning them, that will be prying.”

Sulphadoxine-pyrimethamine is even more popular, as it is affordable and generally believed to be “really strong”.

“When I have malaria and I have treated with ACTs and I still test positive, my doctor gives me fansidar, it cures the malaria fast,” Nike Majekodunmi (not real name) said, even though she would not reveal the hospital’s name.

“When my family is sick, we take amalar,” a man named Usman, said.

“That is what we use and it is cheap and effective.”

Chloroquine was used to treat malaria all over the world, but now it is no longer a first-line treatment.

Also sulphadoxine-pyrimethamine is no longer recommended for the treatment of malaria in Nigeria even though it has proven effective for the use of intermittent preventive treatment during pregnancy.

Godwin Ntadom of the case management and drug policy unit of the National Malaria Control Programme explained the consequences of using these drugs for the treatment of malaria.

“The consequences of usage is that you will not get cured. So when you use, it makes malaria worse and makes the parasite more stubborn,” he said.

According to the National Guidelines for Diagnosis and Treatment of Malaria, the impact of drugs that have become resistant to malaria is “insidious”.

“The initial symptoms of the infection resolve and the patient is better for weeks,” the organisation said.

“When symptoms recur, usually more than two weeks later, anaemia has worsened and there is a greater probability of carrying gametocytes (which in turn carry the resistance genes) and transmitting malaria. But the patient and the doctor or dispenser may interpret this as a newly acquired infection. At this stage unless drug trials are conducted, resistance may be unrecognised.”

This eventually increases the mortality rate and according to the guideline, is responsible for the failure to control malaria in many areas of the tropical world and the consequent increase in mortality rates worldwide.

WHY THEN ARE THE DRUGS STILL BEING SOLD

“Chloroquine has other effects apart from anti-malaria effect,” Ntadom explained.

“It can be used as an analgesic because it has anti- inflammatory effects.”

“Even when it is not working for malaria, it can be used for pain or weakness; chloroquine will get you relief.”

“It can still be used to treat arthritis and the symptoms associated with arthritis.

“Sulphadoxine-pyrimethamine is still being used by pregnant women to prevent malaria. Both drugs are very cheap.”

Ntadom explained that though there is a written policy that stops the usage of chloroquine  and sulphadoxine-pyrimethamine for the treatment of malaria, it is not being enforced.

“At the chemist level, we don’t have a structure,” he said, adding that the National Agency for Food and Drug Administration and Control (NAFDAC) is saddled with the responsibility of regulating the sale of these drugs – especially over the counter – when they really should be prescription only medication.

“We are not a regulatory body, NAFDAC is. We create awareness and we make alternative treatments,” Ntadom said.

“For instance, we have made ACTs highly accessible and they are now being sold at N150.”

At a press conference in November 2016, Ernest Nwokolo, malaria programme director at the Society for Family Health, also spoke about discounted malaria drugs made available through the help of global funds. The discounted ACTs are recognised through a green leaf logo on the pack of the antimalarial medicines.

Nwokolo said malaria drugs with the green logo are produced by the same company that produce expensive drugs.

This reporter went in search of these green leaf ACTs to find out if they are truly affordable, and they are! More affordable than other brands of ACTs, but still more expensive than monotherapies.

The price of ACTs with green leaf ranges from N350 to N450, (mainly as a result of the naira to dollar exchange rate) depending on the pharmacy or chemist you go to, as opposed to N1000- N2,500 for non-greenleaf brands.

However, chloroquine sells for N250 and sulphadoxine-pyrimethamine sells for just N100, an obvious reason it is really popular.

Nkechi Ezie, deputy director, pharmacovigilance and post marketing surveillance of NAFDAC, said the drugs are still being used because Nigerians do not bother with information.

“People are not well informed,” she said.

“People are not well informed. We create awareness through our enlightenment campaign asking people to go to the hospitals and we keep enlightening people.”

Ezie said NAFDAC had already stopped registering chloroquine for the treatment of malaria and has now made it a Prescription Only Medication that is used for treatment of other diseases.

“Before it was an Over the Counter drug but it is now a prescription only drug,” she said.

“People should be treated for malaria on prescription only. Chloroquine is not a prescription drug and is not for the treatment of malaria any longer.

“If anyone is found selling chloroquine as an OTC, the person will be sanctioned.

“POMs are not advertised except in medical journals.

“As we have complaints, we will deal with it. Regulation evolves out of our customer observation, we investigate and make changes.

“We prosecute and take to court and the judge determines the sanction.”

Data credit: Impact Africa