Influence of blister packaging on the efficacy of artesunate + mefloquine over artesunate alone in community-based treatment of non-severe falciparum malaria in Myanmar.

Three studies were carried out to determine the need, acceptability, and efficacy of adding mefloquine to artemisinin derivatives (AD) for the first-line treatment of uncomplicated falciparum malaria. The first was a retrospective study of 255 basic health workers which showed that their recommendation of AD to patients depended on their level of training. None of the paramedics/midwives and only 9% of 129 doctors had prescribed AD, and no one had recommended AD in combination with mefloquine; 72% of patients used courses that were too short for parasitological cure. To promote the addition of mefloquine to AD regimens we conducted intervention workshops with health care providers and subsidized the cost of mefloquine to patients. In the second study, we interviewed 200 patients before and after the intervention to evaluate drug compliance with full doses of AD and use of subsidized mefloquine. After the intervention, we found that only 3.6% had used mefloquine and 62% had taken non-curative doses of AD. In the third study, we provided blister packs of medication in daily doses and compared the intake of AD + placebo (158 patients) with that of AD + mefloquine (222 patients) for 5 days. The compliance with both regimens was 99%. Blood smears for parasites on day 28 showed one positive in the AD + mefloquine group and 7 positive in the AD group. We conclude that provision of blister packs of daily doses is a very effective way to improve compliance with short courses and drug combinations, but the efficacy of the combination in Myanmar in this particular study was only marginally higher than that of AD alone.