"A looming threat to malaria control is the emergence of parasites that are resistant to anti-malarial medicines," stated World Health Organisation (WHO) in its ‘Global Plan for Artemisinin Resistance Containment' published in 2011. The strains that are resistant to even artemisinin have emerged in parts of South East Asia and could potentially spread, as has happened with previous anti-malarial drugs.

Delivering Artemisinin and its derivatives as monotherapies, instead of as a cocktail with another drug, create opportunities for resistant forms of the parasite to arise and spread. Although oral Artemisinin-based monotherapies are effective when taken as the full seven-day course, patients often stop taking them after a few days when symptoms subside. Parasites that are sensitive to the drug get eliminated, allowing drug-resistant strains to proliferate and get transmitted to other people. WHO, in 2006, called for a halt on using oral Artemisinin monotherapies for treating uncomplicated malaria. A year later, a resolution was adopted by the World Health Assembly, WHO's apex decision-making body, that urged its member states to "cease progressively" the provision, in both public and private sectors, of such monotherapies and promote the use of ACTs.

However, according to the latest World Malaria Report 2011, 25 countries are still allowing the marketing of these products and 28 pharmaceutical companies, as against 39 a year ago, are making these drugs. The report has also warned that there are Indian pharmaceutical companies among those manufacturing and marketing drugs that are likely to foster resistance to artemisinin in the malaria parasite. Ten of the 28 manufacturers of monotherapies are reportedly based in India.
The Drug Controller General of India (DCGI) initiated action earlier this year to stop the production and export of these drugs. It wrote to all state drugs controllers requesting them to cancel licenses for manufacturing oral Artemisinin-based monotherapies with immediate effect.

Addressing the menace

According to WHO, India is of greatest concern as there is widespread DDT-resistance and patches of resistance to pyrethroid and organophosphate (malathion). WHO has recommended that an Artemisinin-based combination therapy (ACT) should be the first-line treatment for uncomplicated malaria caused by P. falciparum. The two-drug combination reduces the chances of the parasite developing resistance. Moreover, a three-day course of a recommended ACT generally clears the parasites from the body.

Guidelines of National Institute of Malarial Research (NIMR) too recommends combination therapy for P. falciparum. Arterolane maleate, a rapidly acting drug in combination with long-acting piperaquine phosphate, is an anti-malarial product in line with WHO-recommended combination therapy for the treatment of uncomplicated P. falciparum malaria. Though insecticide and spraying materials and insecticide-treated nets are other possible solutions to control malaria, but they have not been very successful in India so far.