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Audibert C, Aspinall A, Tchouatieu AM, Hugo P. Evaluation of Segmentation, Rotation, and Geographic Delivery Approaches for Deployment of Multiple First-Line Treatment (MFT) to Respond to Antimalarial Drug Resistance in Africa: A Qualitative Study in Seven Sub-Sahara Countries. Trop Med Infect Dis 2024; 9:93. [PMID: 38787026 PMCID: PMC11125622 DOI: 10.3390/tropicalmed9050093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Several studies recently confirmed the emergence of resistance to antimalarial drugs in sub-Saharan Africa. Multiple first-line treatment (MFT) is one of the measures envisaged to respond to the emergence and spread of this resistance. The aim of this study was to identify the perceived advantages and disadvantages of several MFT deployment strategies and to better understand potential implementation drivers and barriers. METHODS A qualitative survey was conducted in seven sub-Saharan countries amongst key opinion leaders, national decision makers, and end users. A total of 200 individual interviews were conducted and findings were analyzed following a thematic inductive approach. RESULTS From a policy perspective, the new MFT intervention would require endorsement at the global, national, and regional levels to ensure its inclusion in guidelines. Funding of the MFT intervention could be a bottleneck due to costs associated with additional training of healthcare workers, adaptation of drug delivery mechanisms, and higher costs of drugs. Concerning the MFT deployment strategies, a slight preference for the segmentation strategy was expressed over the rotation and geographic approaches, due to the perception that a segmentation approach is already in place at country level. CONCLUSIONS The findings highlighted the need for a collective approach to MFT deployment through the engagement of stakeholders at all levels of malaria management.
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Affiliation(s)
- Celine Audibert
- Medicines for Malaria Venture (MMV), Route de Pre-Bois 20, 1215 Meyrin, Switzerland; (A.A.)
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Cao VAT, Nguyen TQ, Le Quyen D, Boon WPC, Moors EHM, Dondorp AM, de Haan F, Amaratunga C. Exploring the feasibility of introducing triple artemisinin-based combination therapy in the malaria treatment policy in Vietnam. Malar J 2023; 22:326. [PMID: 37898749 PMCID: PMC10613363 DOI: 10.1186/s12936-023-04763-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND This study investigates the processes regarding changing malaria treatment policies in Vietnam. Moreover, it explores the feasibility of introducing triple artemisinin-based combination therapy (TACT) in Vietnam to support the national malaria control and elimination plan. METHODS Data were collected via 12 in-depth interviews with key stakeholders, combined with a review of policy documents. RESULTS TACT is considered as a useful backup strategy in case future treatment failures with current artemisinin-based combination therapy (ACT) would occur. Moreover, TACT is also considered as a promising strategy to prevent the re-establishment of malaria. However, regulatory procedures and implementation timelines for TACT were expected to be lengthy. Therefore, strategies to engage national decision-makers, regulators, and suppliers should be initiated soon, stipulating the benefits of TACT deployment. In Vietnam, a procedure to apply for an import permit without registration that has previously been applied to the introduction of artesunate-pyronaridine was proposed to accelerate the introduction of TACT. Global-level support through the World Health Organization recommendations and prequalification were considered critical for supporting the introduction of TACT in Vietnam. CONCLUSIONS Appropriate approach strategies and early stakeholder engagement will be needed to accelerate the introduction of TACT in Vietnam.
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Affiliation(s)
- Van Anh Thi Cao
- The University of North Carolina Project Office, Hanoi, Vietnam.
| | - Thieu Quang Nguyen
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | | | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Ellen H M Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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de Haan F, Amaratunga C, Thi VAC, Orng LH, Vonglokham M, Quang TN, Lek D, Boon WPC, Dondorp AM, Moors EHM. Strategies for deploying triple artemisinin-based combination therapy in the Greater Mekong Subregion. Malar J 2023; 22:261. [PMID: 37674172 PMCID: PMC10483751 DOI: 10.1186/s12936-023-04666-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND This is a qualitative study to identify implementation challenges for deploying triple artemisinin-based combination therapy (TACT) in the Greater Mekong Subregion (GMS) of Southeast Asia and to explore strategies to overcome these challenges. METHODS In-depth interviews were conducted in three countries that have repeatedly been confronted with ACT failures: Cambodia, Vietnam, and Lao PDR. Thirty-nine key stakeholders in the healthcare systems in these countries were interviewed. One participatory workshop was conducted in Cambodia, where scenarios for potential TACT deployment were discussed. RESULTS The results section is organized around four strategic themes that emerged from the data: policy support, data and evidence, logistics and operation, and downstream engagement. The study revealed that countries in the GMS currently rely on ACT to eliminate Plasmodium falciparum malaria by 2025. TACT is, however, considered to be a useful backup strategy in case of future treatment failures and to prevent the re-establishment of malaria. The study showed that a major challenge ahead is to engage decision makers and healthcare providers into deploying TACT, given the low case incidence of falciparum malaria in the GMS. Interview respondents were also skeptical whether healthcare providers would be willing to engage in new therapies for a disease they hardly encounter anymore. Hence, elaborate information dissemination strategies were considered appropriate and these strategies should especially target village malaria workers. Respondents proposed several regulatory and programmatic strategies to anticipate the formation of TACT markets in the GMS. These strategies include early dossier submission to streamline regulatory procedures, early stakeholder engagement strategies to shorten implementation timelines, and inclusion of TACT as second-line therapy to accelerate their introduction in case they are urgently needed. CONCLUSIONS This paper presents a qualitative study to identify implementation challenges for deploying TACT in the GMS and to explore strategies to overcome these challenges. The findings could benefit researchers and decision makers in strategizing towards potential future deployment of TACT in the GMS to combat artemisinin and partner drug resistance.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands.
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Van Anh Cao Thi
- The University of North Carolina Project in Vietnam, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Long Heng Orng
- Mahidol Oxford Tropical Medicine Research Unit, Epidemiology Department, Mahidol University, Bangkok, Thailand
| | - Manithong Vonglokham
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane Capital, Lao PDR
| | - Thieu Nguyen Quang
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Dysoley Lek
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ellen H M Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
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van de Burgwal L, van der Valk T, Kempter H, Gadau M, Stubbs D, Boon W. An elephant in the glasshouse? Trade-offs between acceleration and transformation in COVID-19 vaccine innovation policies. ENVIRONMENTAL INNOVATION AND SOCIETAL TRANSITIONS 2023; 48:100736. [PMID: 37250374 PMCID: PMC10208527 DOI: 10.1016/j.eist.2023.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
Against the backdrop of a failing vaccine innovation system, innovation policy aimed at creating a COVID-19 vaccine was surprisingly fast and effective. This paper analyzes the influence of the COVID-19 landscape shock and corresponding innovation policy responses on the existing vaccine innovation system. We use document analysis and expert interviews, performed during vaccine development. We find that the sharing of responsibility between public and private actors on various geographical levels, and the focus on accelerating changes in the innovation system were instrumental in achieving fast results. Simultaneously, the acceleration exacerbated existing societal innovation barriers, such as vaccine hesitancy, health inequity, and contested privatization of earnings. Going forward, these innovation barriers may limit the legitimacy of the vaccine innovation system and reduce pandemic preparedness. Next to a focus on acceleration, transformative innovation policies for achieving sustainable pandemic preparedness are still urgently needed. Implications for mission-oriented innovation policy are discussed.
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Affiliation(s)
- Linda van de Burgwal
- Athena Institute, Vrije Universiteit, De Boelelaan 1085, Amsterdam, 1081 HV, the Netherlands
| | - Tom van der Valk
- Athena Institute, Vrije Universiteit, De Boelelaan 1085, Amsterdam, 1081 HV, the Netherlands
- Raymond James Corporate Finance, Health Care, London, United Kingdom
| | - Hannes Kempter
- Raymond James Corporate Finance, Health Care, London, United Kingdom
| | - Manuel Gadau
- Raymond James Corporate Finance, Health Care, London, United Kingdom
| | - David Stubbs
- Raymond James Corporate Finance, Health Care, London, United Kingdom
| | - Wouter Boon
- Copernicus Institute, Utrecht University, Utrecht, the Netherlands
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Mokuolu OA, Bolarinwa OA, Opadiran OR, Ameen HA, Dhorda M, Cheah PY, Amaratunga C, de Haan F, Tindana P, Dondorp AM. A framework for stakeholder engagement in the adoption of new anti-malarial treatments in Africa: a case study of Nigeria. Malar J 2023; 22:185. [PMID: 37330469 DOI: 10.1186/s12936-023-04622-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/14/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Recent reports of artemisinin partial resistance from Rwanda and Uganda are worrisome and suggest a future policy change to adopt new anti-malarials. This is a case study on the evolution, adoption, and implementation of new anti-malarial treatment policies in Nigeria. The main objective is to provide perspectives to enhance the future uptake of new anti-malarials, with an emphasis on stakeholder engagement strategies. METHODS This case study is based on an analysis of policy documents and stakeholders' perspectives drawn from an empirical study conducted in Nigeria, 2019-2020. A mixed methods approach was adopted, including historical accounts, review of programme and policy documents, and 33 qualitative in-depth interviews and 6 focus group discussions. RESULTS Based on policy documents reviewed, the adoption of artemisinin-based combination therapy (ACT) in Nigeria was swift due to political will, funding and support from global developmental partners. However, the implementation of ACT was met with resistance from suppliers, distributors, prescribers, and end-users, attributed to market dynamics, costs and inadequate stakeholder engagement. Deployment of ACT in Nigeria witnessed increased developmental partner support, robust data generation, ACT case-management strengthening and evidence on anti-malarial use in severe malaria and antenatal care management. A framework for effective stakeholder engagement for the future adoption of new anti-malarial treatment strategies was proposed. The framework covers the pathway from generating evidence on drug efficacy, safety and uptake; to making treatment accessible and affordable to end-users. It addresses which stakeholders to engage with and the content of engagement strategies with key stakeholders at different levels of the transition process. CONCLUSION Early and staged engagement of stakeholders from global bodies to community level end-users is critical to the successful adoption and uptake of new anti-malarial treatment policies. A framework for these engagements was proposed as a contribution to enhancing the uptake of future anti-malarial strategies.
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Affiliation(s)
| | | | | | - Hafsat Abolore Ameen
- Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, the Netherlands
| | - Paulina Tindana
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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de Haan F, Boon WPC, Amaratunga C, Dondorp AM. Expert perspectives on the introduction of Triple Artemisinin-based Combination Therapies (TACTs) in Southeast Asia: a Delphi study. BMC Public Health 2022; 22:864. [PMID: 35490212 PMCID: PMC9055751 DOI: 10.1186/s12889-022-13212-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Triple Artemisinin-based Combination Therapies (TACTs) are being developed as a response to artemisinin and partner drug resistance in Southeast Asia. However, the desirability, timing and practical feasibility of introducing TACTs in Southeast Asia is subject to debate. This study systematically assesses perspectives of malaria experts towards the introduction of TACTs as first-line treatment for uncomplicated falciparum malaria in Southeast Asia. METHODS A two-round Delphi study was conducted. In the first round, 53 malaria experts answered open-ended questions on what they consider the most important advantages, disadvantages, and implementation barriers for introducing TACTs in Southeast Asia. In the second round, the expert panel rated the relevance of each statement on a 5-point Likert scale. RESULTS Malaria experts identified 15 advantages, 15 disadvantages and 13 implementation barriers for introducing TACTs in Southeast Asia in the first round of data collection. In the second round, consensus was reached on 13 advantages (8 perceived as relevant, 5 as not-relevant), 12 disadvantages (10 relevant, 2 not-relevant), and 13 implementation barriers (all relevant). Advantages attributed highest relevance related to the clinical and epidemiological rationale of introducing TACTs. Disadvantages attributed highest relevance related to increased side-effects, unavailability of fixed-dose TACTs, and potential cost increases. Implementation barriers attributed highest relevance related to obtaining timely regulatory approval, timely availability of fixed-dose TACTs, and generating global policy support for introducing TACTs. CONCLUSIONS The study provides a structured oversight of malaria experts' perceptions on the major advantages, disadvantages and implementation challenges for introducing TACTs in Southeast Asia, over current practices of rotating ACTs when treatment failure is observed. The findings can benefit strategic decision making in the battle against drug-resistant malaria.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands.
| | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Princetonlaan 8a, 3484 CB, Utrecht, the Netherlands
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Ratchathewi DistrictBangkok, 10400, Thailand
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Ratchathewi DistrictBangkok, 10400, Thailand
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de Haan F, Bolarinwa OA, Guissou R, Tou F, Tindana P, Boon WPC, Moors EHM, Cheah PY, Dhorda M, Dondorp AM, Ouedraogo JB, Mokuolu OA, Amaratunga C. To what extent are the antimalarial markets in African countries ready for a transition to triple artemisinin-based combination therapies? PLoS One 2021; 16:e0256567. [PMID: 34464398 PMCID: PMC8407563 DOI: 10.1371/journal.pone.0256567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/09/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Triple artemisinin-based combination therapies (TACTs) are being developed as a response to artemisinin and partner drug resistance in the treatment of falciparum malaria in Southeast Asia. In African countries, where current artemisinin-based combination therapies (ACTs) are still effective, TACTs have the potential to benefit the larger community and future patients by mitigating the risk of drug resistance. This study explores the extent to which the antimalarial drug markets in African countries are ready for a transition to TACTs. METHODS A qualitative study was conducted in Nigeria and Burkina Faso and comprised in-depth interviews (n = 68) and focus group discussions (n = 11) with key actor groups in the innovation system of antimalarial therapies. RESULTS Evidence of ACT failure in African countries and explicit support for TACTs by the World Health Organization (WHO) and international funders were perceived important determinants for the market prospects of TACTs in Nigeria and Burkina Faso. At the country level, slow regulatory and implementation procedures were identified as potential barriers towards rapid TACTs deployment. Integrating TACTs in public sector distribution channels was considered relatively straightforward. More challenges were expected for integrating TACTs in private sector distribution channels, which are characterized by patient demand and profit motives. Finally, several affordability and acceptability issues were raised for which ACTs were suggested as a benchmark. CONCLUSION The market prospects of TACTs in Nigeria and Burkina Faso will depend on the demonstration of the added value of TACTs over ACTs, their advocacy by the WHO, the inclusion of TACTs in financial and regulatory arrangements, and their alignment with current distribution and deployment practices. Further clinical, health-economic and feasibility studies are required to inform decision makers about the broader implications of a transition to TACTs in African counties. The recent reporting of artemisinin resistance and ACT failure in Africa might change important determinants of the market readiness for TACTs.
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Affiliation(s)
- Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | | | - Rosemonde Guissou
- Institut de Recherche en Sciences de la Sante, Bobo-Dioulasso, Burkina Faso
| | - Fatoumata Tou
- Institut des Sciences et Techniques, Bobo-Dioulasso, Burkina Faso
| | - Paulina Tindana
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Wouter P. C. Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Ellen H. M. Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jean Bosco Ouedraogo
- Institut de Recherche en Sciences de la Sante, Bobo-Dioulasso, Burkina Faso
- Institut des Sciences et Techniques, Bobo-Dioulasso, Burkina Faso
| | | | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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