Between 1998 and 2001, the Peruvian Ministry of Health made sweeping changes in its malaria treatment policies in response to a resurgence of disease and the spread and intensification of antimalarial drug resistance. On the Pacific Coast, the first-line treatment for uncomplicated Plasmodium falciparum malaria was changed to combination therapy with sulfadoxine-pyrimethamine plus artesunate; in the Amazon region, mefloquine-artesunate combination therapy was introduced. With these changes in treatment policy, Peru became the first country in the Americas to use combination therapy with an artemisinin drug as its first-line treatment for falciparum malaria and the first country in the world to use two different drug combination therapy regimens based on an artemisinin drug in different regions of the country. This paper describes the process involved in assessing the geographic distribution and intensity of antimalarial drug resistance throughout the country and the use of that information to guide decisions related to national malaria treatment policy.
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The following year, INS staff who had taken part in the study in Iquitos trained Ministry of Health staff in the Departments of Piura and Tumbes on the northern Pacific coast and assisted them in conducting 14-day in vivo efficacy trials at three sites. These studies were funded by the USAID-Government of Peru emerging infectious disease project. The results at all three sites were similar: more than 30% of patients were infected with strains of P. falciparum that were moderately or highly resistant to CQ, but fewer than 5% of strains were resistant
During 1997 and early 1998, a convergence of interests on the part of the Ministry of Health and several other groups working on emerging infectious diseases and antimalarial drug resistance in Peru led to a partnership that ultimately brought about major changes in national malaria treatment policy. The sharp increase in malaria incidence, especially P. falciparum malaria on the north coast and in the Amazon Basin, had alarmed the Ministry of Health, and there was concern that increasing drug resistance might be contributing to the epidemics. At about the same time, the United States Agency for International Development (USAID) mission in Peru was developing a proposal for a large bilateral emerging infectious disease project. During the planning for that project, Peru invited a team from the Centers for Disease Control and Prevention (CDC) to carry out a review of the malaria situation and malaria control program activities in the Amazon region. A fourth member of the partnership, the U.S. Navy Medical Research Center laboratory in Lima, which had received funding from the U.S. Department of Defense for surveillance of emerging infectious diseases, joined about one year later. One of the principal recommendations of the 1998 CDC consultancy was that antimalarial drug resistance testing should be carried out as soon as possible to determine if the existing first-and second-line drugs in the Amazon Basin were still efficacious. USAID agreed to fund the initial study, and the CDC, together with staff from the Instituto Nacional de Salud (INS), the institution responsible for public health research and training within the Peruvian Ministry of Health, developed a protocol for a 14-day in vivo study comparing the efficacy of CQ and SP for the treatment of uncomplicated P. falciparum malaria. This protocol was based on existing WHO recommendations for in vivo drug efficacy testing (10) and was very similar to the PAHO guidelines for such testing in the Americas, which were being developed at about the same time (11).