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 After testing positive for malaria he got a three-day course of
drugs from a community health volunteer in his village but even
though his fever subsided, he continued to be plagued by headaches
and another test still showed positive results.
Experts say his case could be an indication of drug resistance to
the mosquito-borne disease, which has been spreading in Myanmar and
other countries in the Mekong River basin in what threatens to
become the next big global health emergency if it marches on to
India and Africa.
"This was a missed opportunity," said Eisa Hamid, an epidemiologist
working with the United Nations in Myanmar, who specializes in
monitoring and evaluating malaria programs.
Normally, after three days of treatment the farmer's blood should
have been clear of malaria-transmitting parasites.
"With any patient showing positive test results after three days of
treatment, we have to suspect drug resistance, and more
sophisticated blood testing should have been done as he could still
carry the parasites that cause malaria in his blood."
MALARIA'S NEW GROUND ZERO
Malaria death rates dropped by 47 percent between 2000 and 2014
worldwide but it still killed some 584,000 people in 2013, most of
them in sub-Saharan Africa, according to the World Health
Organization (WHO).
Much of the success in fighting the disease is due to the use of
combination therapies (ACTs) based on artemisinin, a Chinese herb
derivative, which is now under threat as malaria parasites have been
building up resistance to the drugs.
Experts say Myanmar, which has the largest malaria burden in the
region, is the next frontier in the spread of resistance to
artemisinin.
Positioned between the Andaman Sea and the Himalayas and bordering
India and China - home to 40 percent of the world's population -
Myanmar is in a unique position to halt the spread of resistance to
India and Africa.
"We need to act fast to avoid a big catastrophe," said Pascal
Ringwald of the WHO's Global Malaria Programme. "The consequences
could be disastrous."
If the problem spreads beyond the region, history would repeat
itself for a third time, as resistance to other malaria drugs
developed in the area before and spread to Africa to claim the lives
of millions, especially children.
But the urgency is far greater this time as new drugs to replace
ACTs are not yet available.
"Artemisinin resistance could wipe out a lot of the gains we've made
in containing malaria and there is nothing yet to replace it," said
Nyan Sint, an epidemiologist and regional malaria officer working
with the government's national malaria control program.
Before being identified in Myanmar in 2008, signs of resistance were
found in Cambodia and since have also been confirmed in Thailand,
Laos and Vietnam, according to the WHO.
Why parasites become resistant to drugs is not entirely clear but
prolonged civil conflict, dense jungles, migration and poor quality
drugs are all believed to play a part.
The human and economic cost of failing to stop the spread would be
huge, according to a model published in the Malaria Journal last
month.
The study estimated an extra 116,000 deaths per year if artemisinin
resistance is not stopped. Medical costs could exceed $32 million
per year, while productivity losses from a rise in cases and deaths
are estimated at $385 million.
WORSE THAN EBOLA?
Francois Nosten, a French malaria expert who has been studying the
disease along the Myanmar-Thai border for about three decades, said
drug-resistance is a quiet menace that is at risk of being
overlooked as world attention focuses on the Ebola outbreak in West
Africa.
"You don't see people dying in the streets, like with Ebola, but the
consequences of it spreading further could be a lot worse," he said.
In Myanmar the partner drugs in ACTs are still working, but they are
already failing in western Cambodia, a sign that the clock is
ticking fast in the fight against drug-resistance.
Some 60 percent of Myanmar's 51 million people live in
malaria-endemic areas, many of them migrants and people in
hard-to-reach rural areas.
The number of people dying from the disease fell sharply after ACTs
became more widely available but the country still recorded 333,871
malaria cases in 2013 and 236 deaths, WHO data shows.
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In Kayin state, formerly known as Karen state, much progress has
been made since a January 2012 ceasefire between the government and
the Karen National Union (KNU), halting one of the world's
longest-running civil wars.
Villages like Min Saw used to have lots of malaria cases but better
access to health care workers since the ceasefire, ACTs, rapid
diagnosis tests and mass distribution of insecticide-treated bed
nets led to a sharp drop.
"We used to have much higher incidence rates," said Saw Ohn Myint, a
community health worker. "But we need more training and more
equipment to continue to make progress."
International aid organizations have been working with ethnic groups
and the government to set up a network of 1,500 village health
volunteers that can dispense ACTs.
But thousands of Kayin's state 1.5 million people remain uncovered
because they are in hard-to-reach areas, sometimes still controlled
by armed ethnic groups restricting access for government health
workers.
Mistrust following five decades of military rule in Myanmar still
runs deep in Kayin state as its people recover from shelling, land
mines explosions and forced displacement.
The situation is also complicated by fake or low-quality
anti-malaria medicines dispensed at village shops, which instead of
killing the parasites only make them stronger.
"This is a big problem," said Kayin State Health Minister Aung Kyaw
Htwe. "We're trying to educate shopkeepers not to sell these drugs
and people not to take them."
In Min Saw, where a package a colorful tablets purportedly
containing anti-malaria drugs sells for as little as 10 cents,
villagers like Ka Lar Nar say sometimes it is easier to buy
medication from the "village quack" than to see a health worker.
ALL-OUT ASSAULT
Under a $100 million, three-year initiative in the Greater Mekong
region, the Global Fund to Fight AIDS, Tuberculosis and Malaria has
allocated $40 million to Myanmar to fight artemisinin resistance.
Part of the plan is an all-out assault to eliminate plasmodium
falciparum, the deadliest malaria parasite, as containment through
bed nets, insecticides and treating only those who test positive no
longer works.
Villages with a high number of infected people will be flooded with
drugs to be taken by everybody, well and sick, to eliminate
falciparum before treatments fail completely. The plan has received
ethical clearance from the Myanmar government.
Nosten, whose team is mapping 800 villages on the Thai-Myanmar
border for potential mass treatment, says elimination is a
challenge, in particular as malaria is worst in remote rural areas
and because of a large number of migrants in the region.
"Some of these villages are five days' walk from the nearest road,"
said Nosten, director of the Shoklo Malaria Research Unit in the
Thai border town of Mae Sot. "But if we don't do it quickly, it will
be too late and millions of people will die."
Mass drug treatments have been tried before with varying success. If
the parasites are only cleared from half the population, the plan
could backfire and boost resistance rather than eliminate it.
It also requires consent of the population but Nosten is confident
that most villagers will participate.
Screening points have also been set up at key locations frequented
by migrant workers where everyone can be tested, no matter whether
they show malaria symptoms.
(Reporting By Astrid Zweynert; Editing by Ros Russell)
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