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Malaria N 8 - Subject N 4

B.A. Rapuoda, J.H. Ouma, K. Njagi, J.A. Otieno, B. Khan, S. Omar

The goal of the National Malaria Control Programme is the reduction of malaria morbidity and mortality by 30% within a period of five years through various interventions. Case management is considered as the most important intervention.
The main strategy recommended by WHO is early diagnosis and prompt treatment with effective anti-malarial drugs. Though chloroquine has been the first line drug for treatment of uncomplicated malaria in Kenya, reports from practitioners and researchers in Kenya suggest that chloroquine is no longer effective for treatment of malaria in certain areas of Kenya.

Short History of Chloroquine Resistance in Kenya
P. falciparum resistance to chloroquine in Kenya was first reported in a tourist in 1979 (Fogh et al., 1979). Thereafter chloroquine sensitivity pattern studies in Kenya were initiated and an indigenous case of resistance to chloroquine was reported in an infant in Kisumu in 1983 (Spencer et al., 1983). Other subsequent chloroquine sensitivity studies in various parts of the country have shown P. falciparum resistance levels ranging from 0% in Turkana (Clarke et al., 1996), 56% in Western Kenya 61% in non-endemic areas and 72% at the Coast (Khan and Nevill, 1996 Unpublished report). However these findings were based on parasitological interpretations of response to treatment with chloroquine rather than data obtained from both parasitological and clinical responses.

Drug Sensitivity Interpretations
One factor recognized in countries where malaria is endemic is that there is usually a high level of asymptomatic parasitemia within the community (Salako et al., 1990). Therefore the interpretation of the resistance of an antimalarial drug may be misleading. In order to bridge the gap between the exclusive parasitological or the clinical interpretation, WHO held an informal meeting in Geneva in 1994 (WHO, 1994) and the group recommended that anti-malarial sensitivity data interpretation be based both on clinical and parasitological responses, it was also recommended that endemic countries of Africa should have an uniform way of interpreting anti-malarial drug sensitivity data so that data from different countries could be comparable.

Kenyan Experience
The Ministry of Health, Kenya, with assistance from WHO conducted sensitivity studies in several epidemiological zones of the country in order to update the National clinical treatment guidelines (MOH, 1994). The results of the studies on the sensitivitiy of P. falciparum chloroquine using the new WHO technique of in vivo testing of antimalaria drugs was carried out among children aged between 6 months and 5 years in Kisumu Bondo and Kwale. The studies revealed that the overall chloroquine resistance in these areas was 66-85 % (Rapuoda et al., 1996).

These results suggest that there is need to replace Chloroquine as the first line drug for treatment of uncomplicated malaria with a more effective drug in certain parts of the country.

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