EDITORIAL

New Recommendation for Malaria Treatment in Indonesia

Erni J. Nelwan
Department of Internal Medicine, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia. Correspondence mail: erni.juwita@ui.ac.id.

Malaria and men have been struggling for many years and the struggle is not yet over. Although, there were some successful report in fighting the disease that has put a big burden on poor and vulnerable populations; the problems particularly related to drug resistance kept rising.1-3 In a country like Indonesia, as one of the malaria endemic countries in South-East Asia, with more than 60% of the total population is at some risk for malaria and 20% are at high risk (with a report of more than 1 case per 1000 population per year), the number of cases has slowly decreased.4,5 Moreover, not like in Africa, most cases are due to Plasmodium falciparum but in some part of the country it could co-exist with Plasmodium vivax.6 For Indonesia itself, to control malaria will have a huge impact not only in the health sector but also in the economy and tourism sectors.7 The health sector will be the one with much benefit because when someone infected by Plasmodium vivax the chance of recurrence of the disease for those that are not even living in the endemic area is high. This of course, will influence the productivity and quality of life. Eventually, people might contract the disease due to activity during work, holiday or blood transfusion which are not screened routinely for malaria parasites. Therefore, the Indonesian government has focus now on a malaria elimination program and also has put it as one of the Millennium Goals of Development indicator for the country together with other infectious diseases like Tuberculosis and HIV/AIDS. In the clinical practice section, the new recommendation of malaria treatment in Indonesia designed by a Group of Malaria experts under the coordination of the Sub directorate of Malaria Control Program of the Ministry of Health has been introduced recently and published in this edition.8 The evidence regarding chloroquine

resistance in vitro and in vivo for the whole region of the country took some time to materialize and shared the usage of the drug for malaria was entirely prohibited. This might due to limited evidence and poor communication between physician in the clinic and the researcher in the field that created a gap of knowledge in clinical practice.9 However, as explained on the article by Kusriati R, the good collaboration as has been created at this time between all institutions concerned for malaria in Indonesia has now decided to provide what is the best treatment option for the infectionof malaria. In addition to that, to assure the availability and distribution of the medication recommended in the guidelines, a procurement system has been designed and was evaluated all year long.8 However, the persistence effort to educate all Indonesian physicians regarding drug resistance and their contribution to the emergence of resistance, is as much as important, as the guidelines and availability of the medication itself. We also will be entertained by the report of Sutanto et.al regarding the efficacy of using another anti malarial drug available in the country, yet not included in the guidelines recommended by the government. This study was conducted in an area with high endemicity for malaria, notably Eastern Sumba, East Nusatenggara and it has been shown safe with high efficacy for treatment of the uncomplicated falciparum malaria.10 The arthemeter-lumfantrin drug that also belongs to artemisin-based combination therapy is not provided for free by the government but widely available in the country.11 As a backbone of malaria treatment, the capacity of all Indonesian doctors to suspect malaria as one of differential diagnosis among various acute febrile illnesses presenting in the clinic with fever and thrombocytopenia should be improved. Moreover the routine test for malaria

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6. Marfurt J, Chalfein F, Prayoga P, Wabiser F, Wirjanata G, Sebayang B, et al. Artemisinin-based combination therapy against P. vivax: Comparative ex vivo activity of next-generation endoperoxides in multidrug resistant field isolates. Antimicrob Agents Chemother. 2012;30. [Epub ahead of print] 7. Sabot O, Cohen JM, Hsiang MS, Kahn JG, Basu S, Tang L, et.al. Costs and financial feasibility of malaria elimination. Lancet. 2010;376:160415. 8. Kusriastuti R, Surya A. New treatment policy of malaria as a part of malaria control programme in Indonesia. Acta Med Indones. 2012;44(3):264-8. 9. Sutanto I, Endawati D, Ling LH, Laihad F, Setiabudy R, Baird JK. Evaluation of chloroquine therapy for vivax and falciparum malaria in southern Sumatra, Western Indonesia. Malar J. 2010;12(9):52. 10. Sutanto I, Suprianto S, Widiaty A, Rukmiyati, Ruckert P, et al. Good efficacy of Artemether-Lumefantrine for uncomplicated Falciparum malaria in Eastern Sumba, East Nusa Tenggara, Indonesia. National malaria treatment policy as a part of malaria control program in Indonesia. Acta Med Indones. 2012;44(3):187-91. 11. Setiawan B and Ministry of Health Republic of Indonesia. Current malaria management: Guidelines 2009. Acta Med Indones. 2010;42(4):258-61.

either rapid diagnostic test or microscopy when it is available should always be conducted as the Ministry of Health no longer approve the use of anti malaria drugs to be used for a diagnosis on clinical signs only.
REFERENCES
1. Price RN, Douglas NM, Anstey NM. New developments in Plasmodium vivax malaria: severe disease and the rise of chloroquine resistance. Curr Opin Infect Dis. 2009;22:430-5. Dondorp AM, Nosten F, Yi P, Das D, Phyo AP, Tarning J, et al. Artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med. 2009;361:455-67. Noedl H, Se Y, Schaecher K, Smith BL, Socheat D, Fukuda MM. Evidence of artemisinin-resistant malaria in western Cambodia. N Engl J Med. 2008; 332(359):2619-20. World malaria report 2010. Impact of malaria control. World health organization. 2010. p. 50-2. Elyazar IR, Gething PW, Patil AP, Rogayah H, Kusriastuti R, Wismarini DM, et al. Plasmodium falciparum malaria endemicity in Indonesia in 2010. Plos one. 2010;6(6):e21315. Epub 2011 Jun 29.

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