Framework for Artemisinin resistance prevention, containment, and elimination in South America

Abstract

[Executive Summary]. Artemisinin-based combination therapies (ACTs) are the recommended treatments for Plasmodium falciparum malaria in all malaria endemic areas of South America. Resistance of P. falciparum to the artemisinin drugs has already been detected in the Greater Mekong subregion of Southeast Asia and would represent a major setback to malaria control efforts if it were to develop in or spread to South America. Although artemisinin resistance has not been confirmed in the Americas, the interior of Guyana, Suriname, and French Guiana and bordering areas of Brazil and Venezuela (together known as the Guiana Shield) share many characteristics with the Greater Mekong subregion that increase the risk for selection of resistant parasites. These characteristics include higher levels of transmission of P. falciparum than in the rest of the Amazon Basin, highly mobile populations, ready availability and widespread use of a variety of antimalarial drugs of questionable quality, including artemisinin monotherapies, and lack of access to and use of formal malaria diagnostic and treatment facilities. Since the emergence of artemisinin-resistant P. falciparum in the Guiana Shield could seriously jeopardize malaria control efforts throughout South America, prevention of multidrug resistance including ACT resistance be seen as one of the highest malaria control priorities in the Region. The present framework outlines a combination of activities intended to prevent the development of artemisinin resistance in South America, or to contain and eliminate resistance if it should be confirmed. It focuses on the Amazon Basin, which, excluding Haiti, accounts for 98% of all P. falciparum infections reported from the Americas. Within the Amazon Basin, particular emphasis is placed on the Guyana Shield, where the risk for selection of artemisinin-resistant strains is probably highest. A longer-term objective of the framework is to eliminate P. falciparum malaria, as this will be the only sure way to avoid the selection of resistant parasites. The overarching goal of this framework is to protect ACTs – both the artemisinin component and partner drugs – as an effective treatment for P. falciparum malaria in the Americas. It is based on the Global Plan for Artemisinin Resistance Containment (GPARC) and lessons learned from ongoing artemisinin resistance containment projects in the Greater Mekong subregion. The framework recommends expanded coverage of malaria diagnostic and treatment services, intensified vector control to drive down transmission, strengthened malaria surveillance, and increased transborder collaboration, especially in terms of efforts to control the sale and use of artemisinin monotherapies. Since it is unlikely that national malaria control programs will be able to implement all the activities described in this framework simultaneously, a list of suggested priority activities has been included in the Annex.