Comparisons of paradigms for antimalarial drug deployment
| . | . | Paradigm . | . | |
|---|---|---|---|---|
| Factor . | Component . | Improved access . | Limitation of drug resistance . | |
| Drug | Dosage | Single dose, therefore long half-life | Short half-life, therefore multiple doses likely | |
| Regimen | Simple - i.e. single dose treatment ideal, but the fewer doses the better | Combinations of drugs typically increase complexity | ||
| Availability | Widely available at most peripheral level | Available at the most peripheral level offering definitive diagnosis and directly observed therapy (DOT) | ||
| Administration | By patient or patient's guardian (in home); directly observed therapy possible if single dose given at clinic/source | DOT is the ideal administration method to ensure adherence to full dosing | ||
| Adherence | Strategies to maximize very important | Because DOT, adherence assured | ||
| Diagnosis | Anyone with reasonable risk of needing malaria therapy, therefore clinical is acceptable | Only of confirmed cases, therefore based on lab-based diagnosis | ||
| Sources of drugs | As many as possible - private sector (including public sector;informal/itinerate drug sellers); traditional healers | Only from licensed and trained personnel/pharmacies and with prescription by appropriately trained and supervised HCW | ||
| Regulatory requirements | Minimal - primarily assurance of quality of drugs being distributed within community | Maximal: Assurance of quality, licensing and monitoring of drug outlets,formal training and supervision of HCW | ||
| Goals of therapy | Clinical relief | Yes | Yes | |
| Stop progression to severe disease | Proven | Assumed | ||
| Prevent death | Proven | Assumed | ||
| Parasitologic cure | Ideal, but not necessary | Necessary | ||
| Interruption of transmission | Ideal, but not necessary | Highly desirable | ||
| Cost per case treated | Relatively low | Likely to be very high | ||
| Follow-up of cases to identify failures | Desirable, but not necessary | Necessary | ||
| Use of 2nd line treatment | Ideally on identification of clinical failure - in practice, multiple attempts with 1st line | Immediately on identification of parasitologic failure | ||
| Need to coordinate with vector control | Reduction in transmission pressure | Not an essential component of drug policy, per se | Very important if not essential | |
| Information, Education and Communication (IEC) Needs | Complex: improved recognition of symptoms, understanding drug choices, dosages and adherence | Simple: go to health sector for diagnosis and treatment | ||
| Health Worker Training and Supervision needs | Simpler: no specific interventions aimed at reducing overtreatment (no change from status quo) | Complex: maintenance of diagnostic competency, recognition of treatment failures, many drug regimens possible | ||
| Evaluation | Process/Implementation | Indicators reflecting availability of drugs in communities; penetration of IEC materials/messages into community; others | Indicators reflecting availability of treatment algorithms, availability of drugs and diagnostic resources at health centers | |
| Outcome/Effectiveness | Difficult: requires understanding of complex community beliefs, behaviors, and practices | Simpler: indicators reflecting understanding and correct use of diagnostic and treatment algorithms by health workers | ||
| Impact | Difficult: HIS systems; demographic surveillance systems; special studies; in vivo evaluations as currently used | Difficult: long term tracking of changes in molecular markers, in vitro and in vivo resistance; demographic surveillance systems,special studies | ||
| . | . | Paradigm . | . | |
|---|---|---|---|---|
| Factor . | Component . | Improved access . | Limitation of drug resistance . | |
| Drug | Dosage | Single dose, therefore long half-life | Short half-life, therefore multiple doses likely | |
| Regimen | Simple - i.e. single dose treatment ideal, but the fewer doses the better | Combinations of drugs typically increase complexity | ||
| Availability | Widely available at most peripheral level | Available at the most peripheral level offering definitive diagnosis and directly observed therapy (DOT) | ||
| Administration | By patient or patient's guardian (in home); directly observed therapy possible if single dose given at clinic/source | DOT is the ideal administration method to ensure adherence to full dosing | ||
| Adherence | Strategies to maximize very important | Because DOT, adherence assured | ||
| Diagnosis | Anyone with reasonable risk of needing malaria therapy, therefore clinical is acceptable | Only of confirmed cases, therefore based on lab-based diagnosis | ||
| Sources of drugs | As many as possible - private sector (including public sector;informal/itinerate drug sellers); traditional healers | Only from licensed and trained personnel/pharmacies and with prescription by appropriately trained and supervised HCW | ||
| Regulatory requirements | Minimal - primarily assurance of quality of drugs being distributed within community | Maximal: Assurance of quality, licensing and monitoring of drug outlets,formal training and supervision of HCW | ||
| Goals of therapy | Clinical relief | Yes | Yes | |
| Stop progression to severe disease | Proven | Assumed | ||
| Prevent death | Proven | Assumed | ||
| Parasitologic cure | Ideal, but not necessary | Necessary | ||
| Interruption of transmission | Ideal, but not necessary | Highly desirable | ||
| Cost per case treated | Relatively low | Likely to be very high | ||
| Follow-up of cases to identify failures | Desirable, but not necessary | Necessary | ||
| Use of 2nd line treatment | Ideally on identification of clinical failure - in practice, multiple attempts with 1st line | Immediately on identification of parasitologic failure | ||
| Need to coordinate with vector control | Reduction in transmission pressure | Not an essential component of drug policy, per se | Very important if not essential | |
| Information, Education and Communication (IEC) Needs | Complex: improved recognition of symptoms, understanding drug choices, dosages and adherence | Simple: go to health sector for diagnosis and treatment | ||
| Health Worker Training and Supervision needs | Simpler: no specific interventions aimed at reducing overtreatment (no change from status quo) | Complex: maintenance of diagnostic competency, recognition of treatment failures, many drug regimens possible | ||
| Evaluation | Process/Implementation | Indicators reflecting availability of drugs in communities; penetration of IEC materials/messages into community; others | Indicators reflecting availability of treatment algorithms, availability of drugs and diagnostic resources at health centers | |
| Outcome/Effectiveness | Difficult: requires understanding of complex community beliefs, behaviors, and practices | Simpler: indicators reflecting understanding and correct use of diagnostic and treatment algorithms by health workers | ||
| Impact | Difficult: HIS systems; demographic surveillance systems; special studies; in vivo evaluations as currently used | Difficult: long term tracking of changes in molecular markers, in vitro and in vivo resistance; demographic surveillance systems,special studies | ||
Table adapted from P. B. Bloland, CDC (unpublished) and Robb et al.(2003).
HCW, health care workers.