By Zheng Qi 2020-07-20

The independent emergence of artemisinin partial resistance across multiple countries in Africa, a continent that bears over 90% of the world’s total malaria burden, has created an urgent public health imperative for a coordinated, proactive global response — one explicitly designed to ensure that fully efficacious, life-saving malaria treatments remain accessible to every at-risk community before the situation escalates into a catastrophic regional crisis. Right now, the most immediate, non-negotiable priority is to deliver targeted technical and financial support to African nations to drastically scale up both phenotypic and genotypic surveillance systems. Phenotypic studies test how well the malaria parasites in a given community actually respond to artemisinin treatments in real clinical settings, while genotypic monitoring uses the well-documented K13 molecular marker to spot resistance-linked genetic mutations in small blood samples from even remote rural areas. Together, these two layers of surveillance create a far more precise, real-time map of exactly how far artemisinin partial resistance has spread, which communities are most affected, and where public health teams need to deploy interventions first. Alongside this expanded monitoring, national and regional health bodies are already developing detailed, actionable preparedness plans to help countries systematically address every structural gap that could allow resistant parasite strains to spread rapidly across borders and communities.

Years of field research and epidemiological analysis have confirmed that artemisinin partial resistance almost never emerges from a single cause; it is the predictable outcome of multiple overlapping, avoidable factors that have slowly eroded the effectiveness of these life-saving drugs over time. These drivers include widespread poor treatment practices in under-resourced clinics, where health workers sometimes incorrectly prescribe incomplete or under-dosed courses of antimalarials. It is also fueled by inadequate patient adherence to the full prescribed antimalarial regimens, when people stop taking their pills as soon as their fever fades, leaving a small number of surviving parasites in their body that have had time to develop partial drug tolerance. Compounding all this harm is the unregulated, widespread availability of oral artemisinin-based monotherapies — treatments that contain only artemisinin without the required partner drug — and the circulation of counterfeit, substandard forms of the drug that contain little to no active ingredient. These unregulated products expose parasites to low, non-lethal doses of artemisinin, creating the perfect evolutionary pressure for resistance to develop and spread.

Scaling up the full set of interventions needed to stop this resistance in its tracks will demand far more than short-term, one-off funding injections. It will require considerable, sustained financial resources from global donors and national governments, consistent long-term political commitment that survives changes in leadership, and robust, trusted cross-border cooperation between neighboring African nations to stop resistant parasites from moving freely across unregulated border crossings with migrant worker populations. One of the most time-sensitive, high-stakes challenges in this work is to drastically strengthen national pharmaceutical market regulation systems, to systematically identify, seize, and permanently remove all illegal oral artemisinin-based monotherapies and dangerous substandard medicines from local markets, eliminating this major driver of resistance at its source.

In November 2022, WHO formally launched a landmark new Strategy to Respond to Antimalarial Drug Resistance in Africa, a continent-wide framework built on lessons learned from 15 years of experience tackling drug resistance in the Greater Mekong Subregion. This strategy sets clear, actionable targets to tackle growing drug resistance through three core lines of action: systematically tracking the spread of resistant parasite strains across every high-burden region, identifying and prioritizing support for the populations most at risk of treatment failure, and investing in research and development to create and roll out viable, next-generation alternative treatments before existing ACTs lose their effectiveness. Even with this growing threat, ACTs remain the safest, most effective best available treatment for uncomplicated P. falciparum malaria in nearly every part of the world. It is absolutely imperative that the emergence of artemisinin partial resistance does not lead health care providers or patients to hesitate to correctly prescribe and complete full courses of ACTs to treat every confirmed malaria case, as this life-saving therapy still delivers a full cure for nearly all patients when used correctly.

Edited by: Secretariat of the Asia-Pacific Network for Drug and Diagnostics Innovation
Produced by: Zheng Qi
Reviewed by: Zhang Haobing
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