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The bitter truth about quinine

By Flavia Nassaka

Health workers say continued use of discontinued malaria drug is because of limited supplies. But that is only part of the story.

Quinine can be a troublesome drug. Maria Nalubega, a senior nursing officer, is quite familiar with that. She still uses the discontinued drug to treat complicated cases of malaria at Kyarusozi Health Center IV in the rural district of Kyenjojo in western Uganda. In fact, she is a sort of expert at it.

When we met, she was in a queue at the Uganda Institute of Allied Health and Management Sciences in at Mulago National Referral and Teaching Hospital in Kampala. Together with many others queuing in front of a small window, she was braving the scorching sun to pick application forms to attend a course in the coming semester.

Even as the line grew longer, Nalubega kept jumping out to receive seemingly endless calls from colleagues at her hospital inquiring about how to handle the different cases they receive. In one call, she was giving guidelines on how to handle a malaria case with quinine. She says they are forced to use quinine because they at the moment do not have the recommended treatment – artesunate injection.

“When we don’t have artesunate, we use quinine to manage complicated malaria. We don’t use it as an injection but put it in the drip,” she says.

She says administering quinine can be troublesome and requires a lot of skill and knowledge. Nalubega explains that the health worker has to be cautious, take the patient’s body weight, and calculate the time intervals in which the drug should be administered.  She said this can be cumbersome in a country like Uganda where a single doctor or nurse has to work on hundreds of patients.

But there is more. Experts also found quinine has more adverse side effects than artesunate. Patients who use quinine complain of dizziness, hearing loss and the drug breaks down sugars in blood. In fact, research by Médecins Sans Frontières found that treatment with artesunate reduced the risk of death by 39% in adults and 24% in children. That is when the World Health Organisation (WHO) in 2010 replaced quinine, which had for long been the standard treatment for malaria, with injectable artesunate.

Why quinine persists

Uganda embarked on changing the malaria treatment policy in 2011 upon recommendation by WHO and since then the recognised treatment has been Artemisinin Combination Treatment (ACTs) which include coartem, duo-cotecxin, rectal artesunate and injectable artesunate. For severe malaria, this largely remains on paper.

But research conducted in 20 districts across the country found that despite the change of guidelines for treating severe malaria, health workers in these areas still use quinine.

Done by the Malaria Consortium, an international non-governmental organization focusing on malaria treatment and prevention, the same research was done in other countries with a high malaria burden including Cameroon, Malawi, Kenya, Nigeria and Ethiopia to find out whether the interventions into preventing the predicament are yielding results.

In Uganda, two researches were conducted whereby one focused on how severe malaria is managed and the other focused on management of uncomplicated malaria.

According to Dr. Godfrey Magumba, the Country Director for Malaria Consortium Uganda, results showed that the country is on track on managing uncomplicated malaria as 91% of health workers in the 424 cases considered was using the recommended coartem as the first line drug and duo-cotecxin as the second line drug. Only 9% of the cases with uncomplicated malaria were not treated appropriately.

However, results were not good with severe malaria which accounts for 30% of all hospital admissions and 10% of all hospital deaths in the country. Only 37% of the 769 cases considered in this research had received rectal artesunate as pre-referral treatment to interrupt disease progression before being initiated on the main treatment. Also, 63.9% of those admitted in hospital received quinine instead of injection artesunate.

Dr. Mathew Emer, the District Health Officer for Apac district, the area which has been ranked the most malarial on earth  told the Independent on Mar.18 that health workers are aware of the WHO guidelines but sometimes quinine is the only option they have.

His view is shared by Nalubega who says artesunate is supplied in smaller numbers compared to other drugs and health workers suffer stock outs all the time.

“I can’t compel someone to go buy artesunate when they can’t afford and I can’t let them die when I have quinine in plenty,” she says, “Quinine is a good drug if one is following the precautions in administering.”

But Magumba says quinine use persists because health workers are used to it and so it’s hard for them to spare time and learn how to use the new drugs. He says often both drugs are available but quinine is preferred by some health workers.

Dr. Jimmy Opigo, the Manager of the National Malaria Control Programme at the Ministry of Health is well aware of both the challenge of drug shortages and lack of training of health workers in new management of the disease. But he says the problem is bigger.

He said the bigger problem is that malaria is managed at the national level when what is needed is a framework to detect spikes of the disease at the district level.

He likes to compare malaria and HIV, which he says receives more visibility as an epidemic. He says while 1.4 million cases of HIV infections are handled, about 16 million cases of malaria are managed every year and 95% of the population is at risk. Annually, between 70,000 and 100,000 people die of malaria and, since 2015, at least 10 districts of Northern Uganda have been seeing a severe malaria outbreak which had claimed 658 people by January 2016.

Because of this, malaria-related expenses have remained high as the Health Ministry spends over 34% of its total expenditure on it with no hope of this changing any time soon as scientists have not yet come up with a widely effective vaccine for the predicament for many years. But Opigo says the challenges of tackling malaria should not be focused on financing only.

“A lot of money has been released focusing on Malaria like Global Fund, PEPFAR, President’s Malaria Initiative,” he says, “the war against HIV is being won because of actions being down at the district level”.   To win against malaria, the effort should also be at that level.

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