Antimalarial drug combination chemotherapy in malaria case management in Tanzania: how did it come about?

Background & literature review Malaria is a major public health and socioeconomic problem in sub-Saharan Africa including Tanzania. It is estimated that every year between 300 and 500 million clinical cases of malaria occur [1], and approximately one million deaths result as a direct consequence of infection with Plasmodium falciparum [2]. Malaria-related morbidity and mortality are more prevalent in children [3]. Furthermore, malaria infection during pregnancy is a major public health problem in tropical and subtropical regions throughout the world. Pregnant women constitute the second main adult risk group for malaria and 80% of deaths due to malaria in Africa occur in pregnant women and children under 5 years of age [101]. It is estimated that in Africa over 30 million women become pregnant annually and most of these women live in areas of stable malaria transmission [101]. Although human malaria is caused by four parasite species of Plasmodium, most infections and severe morbidity and mortality are caused by P. falciparum, which has been shown to be common in pregnant than nonpregnant women and to have substantial adverse effects on pregnancy outcomes including low birth weight, fetal distress, premature labor, intrauterine growth retardation and an increased number of still births, miscarriages and neonatal deaths. Acute P. falciparum malaria during pregnancy is considered to be particularly dangerous, since the underlying anemia can be dramatically exacerbated by red blood cell destruction. However, malaria is commonly asymptomatic during pregnancy and is not always diagnosed. A clinical trial in Kenya reported that presumptive treatment of all pregnant women in endemic malarial areas with only two doses of sulfadoxine/pyrimethamine (SP) reduced the incidence of anemia among first-time mothers by 39% [2]. The malaria situation is deteriorating every year in Tanzania [4], as evidenced by widespread P. falciparum resistance to chloroquine (CQ) [5], loss of efficacy due to resistance against SP, and increasing malaria-related morbidity and mortality [102]. Resistance to CQ and SP has severely compromised effective treatment and malaria control programs in most sub-Saharan countries. Malaria is a major public health and socioeconomic problem in sub-Saharan Africa including Tanzania. Every year about one million deaths result as a direct consequence of infection with Plasmodium falciparum. In Tanzania the malaria situation is worsening every year, as malaria-related morbidity and mortality is increasing. This situation has been worsened by the development and widespread of Plasmodium falciparum resistance to chloroquine (CQ) and followed by loss of efficacy due to development of resistance against sulfadoxine-pyrimethamine (SP). Hence, this has severely compromised effective treatment and malaria control programs in most sub-Saharan countries including Tanzania. The aim is to review various literatures using google, medline/PubMed search and publications on the drawbacks that have led to most sub-Saharan countries, including Tanzania, phasing out both CQ and SP, which were effective and cheap/affordable first-line drugs for clinical management of uncomplicated malaria. However, despite drawbacks of resistance to SP, the drug is still used for intermittent presumptive prophylactic treatment for pregnant women and infants, and CQ for patients with sickle cell anemia in mainland Tanzania. Thus, early recognition/diagnosis and prompt effective treatment with recommended first-line antimalarials including the use of long-lasting insecticide treated nets remains the mainstay of malaria control strategies in Sub-Saharan Africa. Furthermore, there is a strong need for improved understanding on optimizing malaria treatment policies so as to prevent/ minimize the development and spread of drug resistant malaria by improving compliance, drug quality, rational prescribing and rational use of antimalarial drugs in sub-Saharan countries.