With the reported surge in new malaria cases and growing drug resistance, Rwanda is looking to introduce new antimalarial drugs to combat malaria resistance to already existing drugs on the market, such as Coartem. As part of efforts to tackle the growing resistance to treatments, the government is set to deploy two new antimalarial drugs, namely Dihydroartemisinin-piperaquine (DHAP) and artesunate-pyronaridine (ASPY). ALSO READ: Rwanda to introduce new drugs to combat malaria resistance These two drugs are among the new ones recommended by the World Health Organisation (WHO) for the treatment of uncomplicated malaria among children and adults, under what it calls artemisinin-based combination therapies (ACTs). In 2022, the WHO introduced new strategies to combat antimalarial drug resistance, encouraging countries where malaria is on the upsurge to prioritise the development of new combination therapies that don't contain artemisinin. Among other things, the global health body urged countries to use multiple first-line drugs that can help evade resistance, including manufacturing at the local level and adding low doses of transmission-blocking medicines that can help avoid resistance. Where resistance to existing drugs is increasingly manifested, WHO encourages countries to switch drug schemes, based on the type of malaria being detected, to ensure efficacy, as well as new vector control methods. In an interview with The New Times, Dr. Aimable Mbituyumuremyi, Division Manager of the Malaria and Other Parasitic Diseases Division at the Rwanda Biomedical Centre (RBC), explained the processes and guidelines the country follows to introduce new drugs to combat resistance. Mbituyumuremyi pointed out that Rwanda has a national guideline in place – a document that states how malaria should be treated, who should be treated, which drugs to use, among other things. From that point, they look at the estimated number of people who are expected to get malaria infections. “We use these numbers to procure drugs, based on the national need. From that point, we can procure on a regular basis but can make adjustments if we see a drop in malaria cases,” explains Mbituyumuremyi. Dr. Mbituyumuremyi explains that adjustments are also made when there is an increase or upsurge in malaria cases, as is currently the case in Rwanda, and also when resistance to already existing drugs on the market is noted. “We do not underestimate or overestimate,” says Mbituyumuremyi, adding that they also work with other international organisations such as the WHO, whose malaria treatment guidelines inform the national guideline. Mbituyumuremyi says that Rwanda adheres to the international guidelines, which often indicate drugs that can be used to treat malaria. Rwanda picks from that list of recommended drugs. The guideline is regularly updated, based on the current need for urgent drugs, and once approved by the WHO, the country consults with partners such as the Global Fund and USAID, who can support in terms of procurement or manufacturing, among other ways. Once approved, the government taps into its coffers to procure the drugs or receives funding from international partners to make the drugs available. “This is the process we use to select and procure drugs, based on national guidelines, which are based on international guidelines, and also informed by the data we have from our reporting system,” he explains. These malaria treatment protocols are reviewed and updated at least every two years, based on the evolving nature of the disease, which is transmitted by the Anopheles mosquito. According to RBC, the first batch of the two new drugs arrived in the country a week ago, before the drugs were dispatched to hospitals in different parts of the country where many new malaria cases are being detected, beginning this week. What does the WHO strategy say? In November 2022, the WHO launched a new strategy to address the urgent issue of antimalarial drug resistance, particularly in Africa. This was in response to reports from several African countries indicating an emerging resistance of malaria parasites to artemisinin—the core compound in the most effective medicines for treating malaria. ALSO READ: Hope for ‘malaria-free’ world as WHO approves new vaccine WHO noted that parasites in some areas may also be resistant to the drugs commonly combined with artemisinin, which is a concerning trend that requires urgent measures to preserve the efficacy of these medicines. Dr. Pascal Ringwald, who was the Coordinator of the WHO Global Malaria Programme at the time (a position later taken over by Dr. Daniel Ngamije in March 2023), expressed that the issue was a serious concern because artemisinin-based combination therapies (ACTs) remained the best available treatment for malaria. WHO currently recommends six different artemisinin-based combination therapies as first- and second-line treatments for uncomplicated Plasmodium falciparum malaria. These medicines, derived from the plant Artemisia annua, are also more affordable and accessible, making them a cornerstone in the fight against malaria. ACTs combine an artemisinin derivative (such as artesunate, artemether, or dihydroartemisinin) with a partner drug. The artemisinin compound reduces the number of parasites during the first three days of treatment, while the partner drug eliminates the remaining parasites to cure the infection. Drug resistance is a growing global concern WHO reports that artemisinin resistance has been identified in the Greater Mekong subregion of Asia and several areas in Africa, including Eritrea, Rwanda, and Uganda. While resistance to artemisinin alone rarely leads to treatment failure, resistance to both artemisinin and the partner drug in ACT regimens can result in high treatment failure rates, as seen in parts of Asia and Africa in recent years. Although the WHO Rwanda office has yet to release an official statement regarding malaria drug resistance in Rwanda, there have been concerns about emerging drug resistance. Dr. Jules Mugabo, Head of Malaria and Neglected Tropical Diseases at WHO Rwanda, says that the world body is aware of the increase in malaria cases in Rwanda and they have been working closely with the Ministry of Health and RBC since last year. “Since last year, we are noticing an increase in malaria cases, especially in the eastern part of Rwanda, in Nyagatare and Bugesera districts, as well as Gisagara and Nyanza districts in the Southern Province,” “We are aware as WHO and we are working with the ministry in regard to this. The Ministry has established a task force to co-ordinate the response to the increase of malaria cases. Dr Albert Tuyishime, head of Institute of HIV/AIDS Disease Prevention and Control (IHDPC) at Rwanda Biomedical Center (RBC) is the chair of the task force while WHO and USAID are co-chairs of the taskforce,” Mugabo said. He pointed out that they are supporting the Ministry of Health to conduct an assessment to know exactly what are the factors associated with the increase and at the same time, they are supporting national response, among other things, availability of Rapid Diagnostic Test for malaria diagnosis, and malaria drugs for health facilities and community health workers, facilitating RBC to conduct indoor spraying of insecticide and distribution of bed nets in the affected districts. Monitoring of malaria cases The increase of malaria cases was easily noticed since last year because of the strong surveillance system established by Rwanda Biomedical Center. The same surveillance system guides the implementation of evidence-based interventions to respond to the increase of malaria cases.
