Antimalarial mass drug administration: Ethical considerations

Abstract

Falciparum malaria is a major cause of death and illness in tropical countries, particularly in childhood. In endemic countries, a significant proportion of the community is infected with malaria asymptomatically. One promising way to eliminate malaria in low transmission settings is to give the entire population malaria treatment. This is called mass drug administration (MDA) and it raises a number of ethical issues, as possible longterm benefits are uncertain. The effectiveness of MDA is critically dependent on level of participation, so the promised benefits to the community can be annulled by non-participation of a small number of individuals. These potential benefits range, from the permanent elimination of malaria (success) to a transient reduction in the prevalence of infection and the incidence of illness (failure). The drawbacks of MDA are inconvenience, potential toxicity, loss of confidence in the elimination campaign, possible drug resistance (though unlikely) and the potential for a rebound of malaria illness (if immunity is lost and malaria is reintroduced later). Other ethical issues relate to balancing individual and public health interests, and potentially limiting individual autonomy by making MDA compulsory.