Comment

www.thelancet.com Vol 381 June 1, 2013 e16

Artemisinin-resistant malaria in the Asia-Pacic region
Australia is hosting a high-level meeting, Malaria 2012
(Sydney, Oct 31Nov 2), with a key objective to accelerate
action to address artemisinin resistance in the Asia-Pacic
region. In the past decade, much progress has been made
in tackling malaria. WHO estimates that malaria mortality
rates have fallen by more than 25% since 2000.
1
This
decrease is the result of substantial increases in funding for
malaria control and national eorts to ght the disease.
2

The expanded use of artemisinin-based combination
therapy (ACT) has played a major part in reduction of
malaria illness and deaths and is the WHO-recommended
treatment for Plasmodium falciparum malaria worldwide.
3

The continued e cacy of ACT is crucial for ensuring these
gains are not reversed and for the eventual elimination of
malaria. Elimination eorts might be in jeopardy because
of the emergence of artemisinin resistance.
Data from the Greater Mekong subregionthe cradle
of now widespread resistance to previous front-line
antimalarial drugsshow early signs of artemisinin
resistance in at least 13 sites in Cambodia, Burma,
Thailand, and Vietnam.
4
Eorts to contain the spread
of resistance are in place in these countries. However,
a strategic assessment
5
of the response to artemisinin
resistance in the region, supported by the Australian
Agency for International Development and the
Bill & Melinda Gates Foundation, in close collaboration
with WHO, the US Agency for International
Development, and the UK Department for International
Development, notes that, despite the good start, not
enough is being done with the intensity, coverage and
quality to address artemisinin resistance.
The so-called hotspots of artemisinin resistance are
mostly along international borders and in or near forested
areas. Migrant or seasonal workers, often with little
immunity to malaria and inadequate access to health
services, are most aected. Despite focused eorts, cover-
age of these populations with standard malaria con-
trol methods, such as long-lasting insecticidal bednets,
remains insu cient. Trials of innovative approaches such
as repellents or insecticide-treated clothing to protect
workers exposed to malaria risk (eg, night-working
rubber tappers) have been few. Management and control
of artemisinin resistance is further complicated by the
political sensitivities that often surround border areas and
the populations that inhabit them.
The proportion of malaria cases receiving appropriate
diagnostic testing and treatment is increasing across
the region,
6
but factors that favour the emergence
of artemisinin resistance still exist.
1
These include
substandard or counterfeit ACT compounds,
7
under-
dosing, lack of adherence to the full 3-day ACT
treatment, poor follow-up of cases, and widespread
use of oral artemisinin-based monotherapy for un-
complicated malaria, especially in China and Burma.
Interrupted supply of ACT in some regions has
also led to use of inappropriate alternatives. Many
patients treated in the private sector still do not
receive preceding parasitological diagnosis, although
this situation is slowly changing. In early 2011, the
WHO Director-General launched the Global Plan for
Artemisinin Resistance Containment.
8
The plan is
designed to mobilise action to contain and ultimately
eliminate artemisinin resistance where it has emerged,
and to prevent its emergence elsewhere. In regions
of artemisinin resistance, the plan calls for greatly
intensied and comprehensive eorts beyond what is
expected for routine malaria control, including the use
of transmission-blocking instruments and approaches.
9
The assessment
5
noted that, although national
strategies for containment of artemisinin resistance
are generally appropriate, their coverage and quality
are highly variable. The management structures and
responses are not set up to address artemisinin resistance
urgently, particularly in remote areas where capacity
is often weak. Analysis and use of epidemiological and
operational data that could allow local assessment of
coverage and targeting of interventions is also scarce.
Although surveillance for malaria is improving and
technology to capture real-time data has been piloted,
such data are not yet fully used for local responses.
10
To contain artemisinin resistance, the pace and scale
of action needs to accelerate. Ten high-priority action
areas are identied in the assessment,
5
and WHO is
mount ing a plan to speed up the regional response
to artemisinin resistance. The success of this plan will
require increased political and nancial investment
from aected countries and development partners,
rigorous on-the-ground implementation guided by
good data, and rapid expansion when new foci are
detected. Action on preidentied high-priority research
Published Online
October 31, 2012
http://dx.doi.org/10.1016/
S0140-6736(12)61820-0
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Artemisia annua
Comment
e17 www.thelancet.com Vol 381 June 1, 2013
questions is needed, especially assessment of the safety
and e cacy of primaquine as a transmission-blocking
agent as part of comprehensive malaria treatment;
identication of a molecular marker for artemisinin
resistance; and testing of ways to best protect migrants
from Anopheles spp mosquitoes.
The emergence and containment of artemisinin resis-
tance will not result from the actions of one country.
Eective national and regional collaboration and
coordination of all these elementsincluding those
lying outside the mandate of Ministries of Health, such
as the manufacture, private sector use, and export
of oral artemisinin-based monotherapywill also be
crucial. Without scaled-up investment in these areas,
artemisinin resistance, like resistance to previous anti-
malarial drugs such as chloroquine,
11
has the potential to
extend worldwide and threaten the gains of past years,
and those ahead. The cost will be counted in more lives
lost to malaria.
Jim Tulloch, *Benedict David, Robert D Newman, Sylvia Meek
Artemisinin Resistance Assessment Team, Adelaide, SA, Australia
(JT); Australian Agency for International Development, Canberra,
ACT 2601, Australia (BD); Global Malaria Programme, WHO, Geneva,
Switzerland (RDN); and Malaria Consortium, London, UK (SM)
benedict.david@ausaid.gov.au
JT led, and SM participated in, the assessment of the response to artemisinin
resistance in the Greater Mekong sub-region, which was funded by the
Australian Agency for International Development and the Bill & Melinda Gates
Foundation. We declare that we have no conicts of interest.
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