National Anti-Malaria Drug Policy
The main purpose of the national anti-malaria drug policy is to provide a framework for the safe and effective treatment of uncomplicated and severe malaria as well as prevention of malaria in travellers and vulnerable groups, such as pregnant women and young children.All health care providers in both the public and private sectors must be aware of, understand the rationale for, and implement the national anti-malaria drug policy.
An effective treatment policy should aim to:
- Reduce morbidity
- Prevent the progression of uncomplicated disease into severe and potentially fatal disease and thereby reduce malaria mortality
- Reduce the impact of placental malaria infection and maternal malaria-associated anaemia through chemoprophylaxis or preventive intermittent therapy
- Prevent or delay the development of antimalarial drug resistance by correct diagnosis and rational treatment of all malaria positive cases.
National anti-malaria drug policy was first drafted in 1982. Thereafter the policy is being reviewed periodically by the expert committee on chemotherapy of malaria constituted by Director General of Health Services. The recommendations of this committee are being ratified by the Technical Advisory Committee constituted by the MOH&FW under the Chairmanship of Director General of Health Services. The present national drug policy for Malaria (2007) has been framed keeping in view of proper deployment of effective anti malarial drugs and its judicious use for the treatment of clinically suspected and confirmed malaria cases.
Management of malaria case:
- Clinically diagnosis of malaria on the basis of sign and symptoms
- Confirmation of malaria by Laboratory diagnosis/RDK;
- Referral to secondary/tertiary level of care, if necessary;
- Education of patient or family on :
(ii) when to report to health facility
(iii) danger symptoms
(iv) prevention of malaria
- Dispensing the correct drugs of assured quality,( first dose be given preferably by dispenser);
- Patient compliance as per instructions;
Signs and symptoms
Typical: Sudden onset of high fever with rigors and sensation of extreme cold followed byfeeling of burning, leading to profuse sweating and remission of fever by crisis thereafter.The febrile paroxysms occur every alternate day. Headache, body ache, nausea, etc. maybe associated features.
Atypical: In atypical cases, classical presentation as mentioned above may notmanifest. Hence, any fever case in the endemic areas during transmission seasonmay be considered as malaria.
Anti Malaria Drugs
1) Schizonticidal drugs for clinical and parasitological cure
- Chloroquine, Amodiaquine, Quinine, Quinidine, Pyrimethamine, Trimethoprim,Proguanil, sulfonamides in combination with Pyrimethamine, Mefloquine,Halofantrine, Artemisinine and its derivatives like Artesunate, Artemether,Arteether.
2) Gametocytocidal and anti-relapse drugs.
- Primaquine, 8-Aminoquinolines groups, only compound having action ongametocytes and Hypnozoites.
NATIONAL ANTI-MALARIA DRUG POLICY 2007
- All fever cases should preferably be investigated for malaria by Microscopy or RDK.
- The first line of treatment is chloroquine and the second line is ACT (Artesunate+Sulpha Pyrimethamine) combination. In case resistant to these formulations and to treat severe and complicated malaria quinine will be the drug of choice.
- Microscopically positive Pf cases should be treated with chloroquine in therapeutic dose
of 25 mg/kg body weight over three days and single dose of Primaquine 0.75 mg/kg bw on the first day. This practice is to be followed at all levels including VHWs like
DDCs/FTDs/ASHA as well.
- Microscopically positive Pv cases should be treated with chloroquine in full therapeutic
dose of 25 mg/kg body weight over three days. This practice is to be followed at all levels
including VHWs like DDCs/FTDs/ASHA etc. Primaquine.can be given in dose of
0.25mg/kg bw daily for 14 days under medical supervision only to prevent relapse.
- Fever cases positive by RDK should be treated according to the diagnosed species as
described above. However, if RDK for only Pf is used , negative cases showing sign and
symptom of malaria without any other obvious causes should be considered as .clinical
malaria. and treated with chloroquine in full therapeutic dose of 25 mg/kg body weight
over three days.
- In situations where diagnosis by microscopy or RDK is not possible, cases showing sign
and symptom of malaria without any other obvious causes should be considered as
.clinical malaria. and treated with chloroquine in full therapeutic dose of 25 mg/kg body
weight over three days in low risk area while in high risk area single dose of Primaquine
0.75 mg/kg bw should also be given on the first day. This practice is to be followed at all
levels including VHWs like DDCs/FTDs/ASHA as well.
- ACT is the first line of antimalarial drug for treatment of P.falciparum in chloroquine
resistant areas. The dose is 4mg/kg bw of artesunate daily for 3 days + 25mg/ kg bw of
sulfadoxine/Sulfalene + 1.25 mg per kg bw of pyrimethamine on the first day. ACT should
be given only to confirmed P. falciparum cases found positive by microscopy or Rapid
Diagnostic kits. Compliance and full intake is to be ensured.
- The area/PHC showing a treatment failure more than 10% (both Early and Late
Treatment Failures ) to the tested drug chloroquine in the minimum sample of 30 cases,
should be switched over to the alternate antimalarial drug i.e. Artesunate-Sulfa-
Pyrimethamine (ACT) combination.
- Change of drug to second line of treatment may also be implemented in a cluster of
PHCs around the resistant foci after taking into consideration the epidemiological trend of
P.falciparum ( Pf>30%) and clinical response in these areas and approval of Directorate
of NVBDCP.
- Resistance should also be suspected if in spite of full treatment with no history of
vomiting, diarrhea, patient does not respond within 72 hours parasitologically. Such
patients should be given alternative drug i.e. ACT combination and report to concerned
District Malaria /Sate Malaria Officer/ROHFW Pf monitoring teams for monitoring of drug sensitivity status.
- In areas with high disease burden, high proportion of Pf, inadequate facilities for
laboratory diagnosis and the inaccessibility and relatively poor communication facilities
and the Pf chloroquine resistant pockets, ACT may also be given on clinical diagnosis of
malaria by a trained medical officers or trained paramedical personnel after excluding
other common causes of fever.
- The cases resistant to CQ and SP-ACT, oral quinine with tetracycline or doxycline can be prescribed.
- Mefloquine should only be given to chloroquine/multi resistant uncomplicated
P.falciparum cases only in standard doses as prescribed by WHO. This drug is to be
made available through the depot system and only to be provided to patients against the
prescription of medical practitioners supported by laboratory report showing asexual
stage of P.falciparum parasite and not gametocyte alone and other species.
- Primaquine is contra indicated in Pregnant woman and infants.
- Chemoprophylaxis is recommended in selective cases. It is recommended for a)
Pregnant women in high-risk areas and b) travelers including service personnel who
temporarily go on duty to high malarious areas. In chloroquine sensitive areas, weekly
dose of chloroquine will be given but in chloroquine resistant areas it should be
supplemented by daily dose of proguanil. However chemoprophylaxis should not exceed
3 years due to the cumulative toxic effect of chloroquine.
- In severe and complicated P.falciparum malaria cases intra-venous Quinine/ parenteral Artemisinine derivatives (for adults and non-pregnant women only) are to be given irrespective of chloroquine resistance status. In case of non-availability of the above
drugs, Chloroquine 10 mg/kg bw in isotonic saline should be infused over 8 hours
followed by 15 mg/kg bw in the next 24 hours. This treatment may continue till such time
Quinine/Artemesinine derivatives become available.
- Migratory labour/project population: Since these groups belong to high risk category they need to be screened on weekly basis and treated accordingly.
- All the medical, paramedical and village level health volunteers should be adequately
trained before their involvement in the programme.
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