Volume 79, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Multidrug-resistant malaria is a severe public health problem on the Thailand–Myanmar border. Many villagers buy packets of 4–5 mixed medicines (“yaa chud”) from shops without medical assessment as their first-line malaria treatment. In 2000–2001 a local researcher purchased 50 yaa chud from 44 shops around Mae Sot, Thailand and Myawaddy, Myanmar (Burma), for his wife who was said to be pregnant with fever and drowsiness. The tablets/capsules were provisionally identified by appearance and active ingredients determined in a subset by using mass and atomic spectrometry. The most frequently detected active ingredients were acetaminophen (22%), chlorpheniramine (13.4%), chloroquine (12.6%), tetracycline/doxycycline (11.4%), and quinine (5.1%). Only seven bags contained potentially curative medicine for malaria. A total of 82% of the bags contained medicines contraindicated in pregnancy. Inappropriate, ineffective antimalarial drugs on the Thailand–Myanmar border are likely to increase malaria morbidity, mortality and health costs and engender the emergence and spread of antimalarial drug resistance.


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  1. Nosten F, van Vugt M, Price R, Luxemburger C, Thway KL, Brockman A, McGready R, ter Kuile F, Looareesuwan S, White NJ, 2000. Effects of artesunate-mefloquine combination on incidence of Plasmodium falciparum malaria and mefloquine resistance in western Thailand: a prospective study. Lancet 356 : 297–302. [Google Scholar]
  2. Price RN, Nosten F, 2001. Drug resistant falciparum malaria: clinical consequences and strategies for prevention. Drug Resist Updat 4 : 187–196. [Google Scholar]
  3. Carrara VI, Sirilak S, Thonglairuam J, Rojanawatsirivet C, Proux S, Gilbos V, Brockman A, Ashley EA, McGready R, Krudsood S, Leemingsawat S, Looareesuwan S, Singhasivanon P, White N, Nosten F, 2006. Deployment of early diagnosis and mefloquine-artesunate treatment of falciparum malaria in Thailand: the Tak Malaria Initiative. PLoS Med 3 : e183. [Google Scholar]
  4. White NJ, 1999. Antimalarial drug resistance and combination chemotherapy. Philos Trans R Soc Lond B Biol Sci 354 : 739–749. [Google Scholar]
  5. White NJ, 2004. Antimalarial drug resistance. J Clin Invest 113 : 1084–1092. [Google Scholar]
  6. Dondorp A, Nosten F, Stepniewska K, Day N, White N, 2005. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet 366 : 717–725. [Google Scholar]
  7. Jaidee S, Limpananon J, Wittayanartpaisal S, 1980. Drug utilization of yaachud in Thailand. Thai J Pharm Sci 5 : 219–220. [Google Scholar]
  8. Wiwat C, Silapaarcha W, Temsirilerkhul R, Chiowatana J, 1982. Rural self-medication in malaria infection. Thai J Pharm Sci 7 : 14–29. [Google Scholar]
  9. Kamolratanakul P, Dhanamun B, Thaithong S, 1992. Human behavior in relation to selection of malaria treatment. Southeast Asian J Trop Med Public Health 23 : 189–194. [Google Scholar]
  10. Plasai V, Spielman A, 1996. Mefloquine insusceptibility of malaria in Thailand not promoted by nonregulated drug-use. Acta Trop 60 : 281–289. [Google Scholar]
  11. Cunningham CE, 1970. Thai “injection doctors”; antibiotic mediators. Soc Sci Med 4 : 1–24. [Google Scholar]
  12. Foster SD, 1991. Pricing, distribution, and use of antimalarial drugs. Bull World Health Organ 69 : 349–363. [Google Scholar]
  13. Amin AA, Hughes DA, Marsh V, Abuya TO, Kokwaro GO, Winstanley PA, Ochola SA, Snow RW, 2004. The difference between effectiveness and efficacy of antimalarial drugs in Kenya. Trop Med Int Health 9 : 967–974. [Google Scholar]
  14. Basco LK, 2004. Molecular epidemiology of malaria in Cameroon. XIX. Quality of antimalarial drugs used for self-medication. Am J Trop Med Hyg 70 : 245–250. [Google Scholar]
  15. Goodman C, Brieger W, Unwin A, Mills A, Meek S, Greer G, 2007. Medicine sellers and malaria treatment in sub-Saharan Africa: what do they do and how can their practice be improved? Am J Trop Med Hyg 77 : 203–218. [Google Scholar]
  16. Brown GW, Saunders JP, Singh S, Huxsoll DL, Shirai A, 1978. Single dose doxycycline therapy for scrub typhus. Trans R Soc Trop Med Hyg 72 : 412–416. [Google Scholar]
  17. Taylor RB, Shakoor O, Behrens RH, 1995. Drug quality, a contributor to drug-resistance. Lancet 346 : 122. [Google Scholar]
  18. Okeke IN, Lamikanra A, Edelman R, 1999. Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerg Infect Dis 5 : 18–27. [Google Scholar]
  19. Noranate N, Durand R, Tall A, Marrama L, Spiegel A, Sokhna C, Pradines B, Cojean S, Guillotte M, Bischoff E, Ekala MT, Bouchier C, Fandeur T, Ariey F, Patarapotikul J, Le Bras J, Trape JF, Rogier C, Mercereau-Puijalon O, 2007. Rapid dissemination of Plasmodium falciparum drug resistance despite strictly controlled antimalarial use. PLoS ONE 2 : e139. [Google Scholar]
  20. Yeung S, White NJ, 2005. How do patients use antimalarial drugs? A review of the evidence. Trop Med Int Health 10 : 121–138. [Google Scholar]
  21. Kachur SP, Black C, Abdulla S, Goodman C, 2006. Putting the genie back in the bottle? Availability and presentation of oral artemisinin compounds at retail pharmacies in urban Dares-Salaam. Malar J 5 : 25. [Google Scholar]
  22. Newton PN, Green MD, Fernandez FM, Day NP, White NJ, 2006. Counterfeit anti-infective drugs. Lancet Infect Dis 6 : 602–613. [Google Scholar]
  23. Fernandez FM, Cody RB, Green MD, Hampton CY, McGready R, Sengaloundeth S, White NJ, Newton PN, 2006. Characterization of solid counterfeit drug samples by desorption electrospray ionization and direct-analysis-in-real-time coupled to time-of-flight mass spectrometry. ChemMedChem 1 : 702–705. [Google Scholar]
  24. Hall KA, Newton PN, Green MD, De Veij M, Vandenabeele P, Pizzanelli D, Mayxay M, Dondorp A, Fernandez FM, 2006. Characterization of counterfeit artesunate antimalarial tablets from southeast Asia. Am J Trop Med Hyg 75 : 804–811. [Google Scholar]
  25. Ward SA, Sevene EJ, Hastings IM, Nosten F, McGready R, 2007. Antimalarial drugs and pregnancy: safety, pharmacokinetics, and pharmacovigilance. Lancet Infect Dis 7 : 136–144. [Google Scholar]
  26. Lee MS, Kerns EH, 1999. LC/MS applications in drug development. Mass Spectrom Rev 18 : 187–279. [Google Scholar]
  27. Tomer KB, 2001. Separations combined with mass spectrometry. Chem Rev 101 : 297–328. [Google Scholar]
  28. Cody R, Laramee J, Durst H, 2005. Versatile new ion source for the analysis of materials in open air under ambient conditions. Anal Chem 77 : 2297–2302. [Google Scholar]
  29. Gaskell S, 1997. Electrospray: principles and practice. J Mass Spectrom 32 : 677–688. [Google Scholar]
  30. WHO Model List of Essential Medicines, 2008. Geneva: World Health Organization.
  31. World Health Organization, 2006. WHO Guidelines for the Treatment of Malaria. Geneva: World Health Organization.
  32. Beers MH, Porter RS, Jones TV, Kaplan JL, Berwits M, 2006. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories.
  33. Anonymous, 2007. British National Formulary. London: BMJ Publishing Group and RPS Publishing.
  34. Ballereau F, Prazuck T, Schrive I, Lafleuriel MT, Rozec D, Fisch A, Lafaix C, 1997. Stability of essential drugs in the field: results of a study conducted over a two-year period in Burkina Faso. Am J Trop Med Hyg 57 : 31–36. [Google Scholar]
  35. Roper C, Pearce R, Nair S, Sharp B, Nosten F, Anderson T, 2004. Intercontinental spread of pyrimethamine-resistant malaria. Science 305 : 1124. [Google Scholar]
  36. Anon., 2007. Resistance to artemisinin derivatives along the Thai-Cambodian border. Wkly Epidemiol Rec 82 : 360. [Google Scholar]
  37. Bousema JT, Gouagna LC, Meutstege AM, Okech BE, Akim NI, Githure JI, Beier JC, Sauerwein RW, 2003. Treatment failure of pyrimethamine-sulphadoxine and induction of Plasmodium falciparum gametocytaemia in children in western Kenya. Trop Med Int Health 8 : 427–430. [Google Scholar]
  38. Price R, Nosten F, Simpson JA, Luxemburger C, Phaipun L, ter Kuile F, van Vugt M, Chongsuphajaisiddhi T, White NJ, 1999. Risk factors for gametocyte carriage in uncomplicated falciparum malaria. Am J Trop Med Hyg 60 : 1019–1023. [Google Scholar]
  39. Tomson G, Sterky G, 1986. Self-prescribing by way of pharmacies in 3 Asian developing-countries. Lancet 2 : 620–622. [Google Scholar]
  40. Wondemagegnehu E, 1999. Counterfeit and Substandard Drugs in Myanmar and Vietnam. Geneva: World Health Organization. WHO Report WHO/EDM/QSM/993.
  41. Lon CT, Tsuyuoka R, Phanouvong S, Nivanna N, Socheat D, Sokhan C, Blum N, Christophel EM, Smine A, 2006. Counterfeit and substandard antimalarial drugs in Cambodia. Trans R Soc Trop Med Hyg 100 : 1019–1024. [Google Scholar]
  42. Patterson AE, Winch PJ, Gilroy KE, Doumbia S, 2006. Local terminology for medicines to treat fever in Bougouni District, Mali: implications for the introduction and evaluation of malaria treatment policies. Trop Med Int Health 11 : 1613–1624. [Google Scholar]
  43. Ratanowijitrasin S, Wondemagegnehu E, 2003. Effective drug regulation: a multicountry study. Essent Drugs Monit 32 : 2–4. [Google Scholar]

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  • Received : 29 Apr 2008
  • Accepted : 05 Jul 2008

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