Responding to regional challenges in Africa
Both the WWARN West and East African teams, in Senegal and Kenya respectively, are working with partners to tailor initiatives that respond to specific regional needs and stakeholder challenges.
In late May, the WWARN East Africa Regional Centre co-organised a regional meeting with the Roll Back Malaria-Eastern Africa Regional Network (RBM-EARN), and the East African Consortium for Clinical Research (EACCR). The Antimalarial Resistance Stakeholders Meeting in Nairobi, Kenya brought together 40 malaria experts – from Burundi, the Republic of Congo, Kenya, Sudan, the United Republic of Tanzania and Uganda – with the ambitious aim to revitalize collaborative efforts and discuss research activities needed to address the threats of artemisinin resistance in East Africa.
The call to put aside national interests and bureaucratic barriers to tackle this threat is particularly pressing, explains Dr Ambrose Talisuna, WWARN East Africa Regional Director. “Two recently-confirmed sites of artemisinin-resistant falciparum malaria in South East Asia throw into sharp focus the growing threat to malaria control and elimination efforts in Africa. If the resistance spreads, we all agree that the greatest potential effects will be in sub-Saharan Africa where disease burdens are highest and systems for resistance monitoring and containment are weak.”
In the 1990s, a standardised system for drug sensitivity monitoring was established by the East African Network for Monitoring Antimalarial Treatment (EANMAT). Dr Talisuna was part of this initiative and has observed the evolution of the networks in the region. The data collected – for eight different drugs at 40 sentinel sites – provided the evidence base for regional antimalarial treatment policy change. After the adoption of highly effective artemisinin combination therapies (ACTs), drug efficacy monitoring became a lower priority and recently has been neglected in many areas.
The only current measure of artemisinin resistance is the speed at which the parasites are cleared from the patient’s blood after treatment. The meeting agreed that more research is needed to understand the mechanism of artemisinin resistance and monitor its possible emergence. The wide diversity of transmission patterns in Africa will certainly require subregional adaptations of research protocols, but agreement of the key baseline parameters will be needed.
“The enthusiastic response to this new initiative indicates the willingness of the regional scientific community to work together. We now turn to regional governments and funders to provide the necessary resources to build an effective system that will allow a robust response to the threat of artemisinin resistance in our region,” concluded co-organiser Dr Joaquim da Silva, RBM-EARN Regional Coordinator.
In West Africa, any response to antimalarial resistance is hampered by the huge geographic spread, and high transmission rates in some of the most densely populated parts of Africa. The burden of malaria is arguably the highest in the world with nearly two-thirds of global malaria deaths being located in West Africa – in Nigeria, Burkina Faso, Cote d'Ivoire and Mali (Roll Back Malaria, 2010).
Dr Louis Penali, who is leading WWARN’s response in West Africa, understands the difficulties. “Our initial task was to contact all the leading regional malaria researchers and secure their buy-in to a strong scientific collaboration.” This effort came to fruition at the first West Africa Stakeholders Meeting held in Ouagadougou last November. Fourteen scientists – from Burkina Faso, Benin, Ghana, Mali, Nigeria, Cote d’Ivoire, Senegal and Gambia – met to discuss regional needs and identify knowledge gaps that might be filled by these malaria chemo-resistance experts.
“To avoid the issues that have hampered former regional networks, the group chose to adopt a light touch on governance, instead focusing on research questions,” explained Dr Penali. Five retrospective study groups were established to examine the regional evolution of artesunate-amodiaquine (AS/AQ), artemether-lumefantrine (AL), sulfadoxine-pyrimethamine (SP), AQ, SP+AQ, ACT and artesunate efficacy.
Dr Philippe Guérin, WWARN Executive Director, concludes: “There cannot be a ‘one size fits all’ approach to survey the epidemiology of antimalarial resistance. We must evolve our response to meet the specific requirements of stakeholders in each region. It is also important that our colleagues on different continents and in diverse environments have a forum for sharing learning and best practices.”