Mutabingwa T K
Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
Acta Trop. 2005 Sep;95(3):305-15. doi: 10.1016/j.actatropica.2005.06.009.
Artemisinin-based combination therapies (ACTs) are the best anti-malarial drugs available now. Artemisinin enhances efficacy and has the potential of lowering the rate at which resistance emerges and spreads. Under low transmission intensity, ACTs have an additional public health benefit of reducing the overall malaria transmission and studies are urgently needed to investigate modalities of attaining similar benefits under high transmission. Despite being recommended by WHO since 2001, overall deployment of ACT has been slow. Limiting factors are high cost, limited knowledge and public awareness on the concept of combination therapy (CT) and ACT in particular, limited knowledge on safety of ACTs in pregnancy, operational issue such as inappropriate drug use, lack of suitable drug formulations, lack of post-marketing surveillance (PMS) systems, and the imbalance between demand and supply. Through concerted efforts of multilateral organizations, the local scientific community with involvement of policy-makers progress has been on several fonts leading to improved ACT uptake rates in the last 2 years. Of 43 countries that had adopted ACT by February 2005, 18 (42%) adopted the policy in 2004. Preference to co-formulated Coartem has led to a surge in its demand with consequent shortage. Alternative ways for increased production of ACTs are urgently needed otherwise most policies will remain adopted on paper. Despite limitations, opportunities are opening up for effective malaria control. Insecticides, insecticide-treated nets (ITNs) and ACTs are proven efficacious controls available that should be accessed by many. Substantial funding is now available for biomedical malaria research and for policy implementation. While the Global Fund is the financial engine behind the scaling up of ACT uptake, delays in cash flow after grant approval has led to many countries adopting ACT in 2004 but only few (nine) implementing it. Clear policies on granted funds and minimal politics within funding agencies might improve the situation. Increased interest in drug development together with the public and private sector partnership have led to new anti-malarials, some less expensive and therefore affordable by poor malaria endemic countries. Dihydroartemisinin-piperaquine (Artekin) has a cost advantage over other ACTs (USD 1 for an adult treatment) making it a potential best candidate for deployment in Africa. Part of available funds should be invested into capacity building and strengthening (personnel, resources and infrastructure) of institutions in malaria endemic countries. This will create enabling environment and a critical mass of scientists and public health experts to spearhead ACT policy implementation. Active involvement of scientists from malaria endemic countries in recent International Scientific Forums like the Malaria in Pregnancy Working Group and the Consortium on ACT Implementation is the best way forward to emulate.
以青蒿素为基础的联合疗法（ACTs）是目前可用的最佳抗疟药物。青蒿素可提高疗效，并有可能降低耐药性出现和传播的速度。在低传播强度地区，ACTs还有减少总体疟疾传播的公共卫生效益，迫切需要开展研究以探讨在高传播地区实现类似效益的方式。尽管自2001年以来世卫组织就推荐使用ACTs，但ACTs的总体推广速度一直很慢。限制因素包括成本高、对联合疗法（CT）尤其是ACT概念的了解和公众意识有限、对ACTs在孕期安全性的认识不足、诸如用药不当等操作问题、缺乏合适的药物剂型、缺乏上市后监测（PMS）系统以及供需失衡。通过多边组织、当地科学界以及政策制定者的共同努力，在过去两年里在多个方面取得了进展，ACTs的使用率有所提高。在截至2005年2月已采用ACTs的43个国家中，有18个国家（42%）在2004年采用了该政策。对复方蒿甲醚（Coartem）的偏好导致其需求激增，继而出现短缺。迫切需要增加ACTs产量的替代方法，否则大多数政策将只能停留在纸面上。尽管存在限制，但有效控制疟疾的机会正在出现。杀虫剂、经杀虫剂处理的蚊帐（ITNs）和ACTs已被证明是有效的控制手段，许多地方都应采用。目前有大量资金可用于生物医学疟疾研究和政策实施。虽然全球基金是扩大ACTs使用的资金来源，但赠款批准后现金流的延迟导致许多国家在2004年采用了ACTs，但只有少数国家（9个）实施了该政策。关于赠款资金的明确政策以及资助机构内部尽量减少政治干预可能会改善这种情况。对药物研发的兴趣增加以及公共和私营部门的伙伴关系催生了新的抗疟药物，其中一些价格较低，贫困疟疾流行国家能够负担得起。双氢青蒿素哌喹（Artekin）比其他ACTs具有成本优势（成人治疗费用为1美元），使其成为在非洲推广的潜在最佳候选药物。部分可用资金应投资于疟疾流行国家机构的能力建设和强化（人员、资源和基础设施）。这将创造有利环境，并培养一批关键的科学家和公共卫生专家来带头实施ACT政策。疟疾流行国家的科学家积极参与近期的国际科学论坛，如妊娠疟疾工作组和ACT实施联盟，是值得效仿的最佳前进方向。
