A link between poor quality antimalarials and malaria drug resistance?

Introduction

Malaria remains a major public health problem for most of the world. The tragedy remains that many more malaria patients would survive if they had timely access to good quality, affordable and efficacious medicines. Antimalarial resistance has been a major impediment to malaria control. Since the 1950s, Plasmodium falciparum parasites have developed resistance to the main antimalarials used in national and international policies, including chloroquine, sulphadoxine-pyrimethamine (SP) and these have spread globally and increased mortality. Recently, resistance to the artemisinin derivatives, associated with falciparum parasite kelch13 mutations, has been described in mainland South East Asia, but not yet confirmed in other endemic regions.

With few new antimalarials in the development pipeline, concern that key artemisinin-combination therapies (ACTs) may fail is of great public health alarm, with both resistance to artemisinin derivatives and partner drugs reported. The risk of geographic spread is very high and would have dramatic consequences for many aspects of society, including health, education, and economy. Suboptimal antimalarial use both poor prescribing and poor adherence, has been invoked as a driver for poor patient outcome and parasite resistance, although see the caution of Noranate et al. (2007). Improved use, through better prescription and discussion with patients so that they know why and how to adhere will be important. Here, we argue that poor quality antimalarials also contribute to drug resistance.