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CW Games special

Beware about malaria in Delhi during common wealth games.

NATIONAL DRUG POLICY ON MALARIA (2010) Guidelines

  • Malaria is a major public health problem.
  • Every year 15 lakh lab confirmed cases of malaria are reported in India.
  • 50% of the total malaria cases are due to P.falciparum.
  • The reason attributed to rise in P.falciparum cases is resistance to chloroquine, which has been used for a long time as the first line of treatment of malaria cases.
  • All fever cases suspected to be malaria should be investigated by microscopy or RDT(Rapid diagnostic tests).

Treatment of uncomplicated malaria

P. vivax

  • Treat with chloroquine for 3 days and Primaquine to prevent relapse for 14 days.
  • Primaquine is contraindicated in pregnant women, infants and individuals with G6PD deficiency.
  • Stop primaquine if hematuria or high colored urine / cyanosis or blue coloration of lips.
  • Chloroquine: 25 mg/kg body weight divided over three days i.e. 10mg/kg on day 1, 10mg/kg on day 2 and 5mg/kg on day 3. (4 tab day 1, 4 tab day 2 and 2 tab day 3)
  • Primaquine: 0.25 mg/kg body weight daily for 14 days.
  • Presumptive treatment with chloroquine is no more recommended.

P. falciparum

  • Treat with artemisinin–based Combination Therapy (ACT)
  • Artesunate 4 mg/kg body weight daily for 3 days plus Sulfadoxine (25 mg/kg body weight) – Pyrimethamine (1.25 mg/kg body weight) on first day PLS single dose primaquine on day 2.
  • Do not give ACT in 1st trimester of pregnancy.
  • Sulphadoxine–Pyrimethamine (SP) tablet contains 500, mg sulphadoxine and 25 mg pyrimethamine.

Pregnant women with uncomplicated P. falciparum

  • 1st Trimester:Quinine salt 10mg/kg 3 times daily for 7 days. It may induce hypoglycemia; pregnant women should not start taking quinine on an empty stomach and should eat regularly while on quinine treatment).
  • 2nd & 3rd Trimester: ACT
  • Primaquine is contraindicated in pregnant woman

Mixed malaria (P. vivax + P. falciparum) cases

Full course of ACT and Primaquine 0.25 mg per kg body weight daily for 14 days.

Severe malaria

  • Artesunate: 2.4 mg/kg body weight IV or IM given on admission (time = 0 h); then at 12 h and 24 h and then once a day
  • Artemether: 3.2 mg/kg body weight IM given on admission and then 1.6 mg/kg body weight per day or
  • Arteether: 150 mg IM daily for 3 days in adults only (not recommended forchildren) or
  • Quinine: 20 mg/kg body weight on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg body weight 8 hourly. The infusion rate should not exceed 5 mg salt/kg body weight per hour. Loading dose of Quinine i.e. 20mg/kg body weight on admission may not be given if the patient has already received quinine or if the clinician feels inappropriate.

Parenteral treatment in severe malaria cases should be given for minimum of 24 hours once started (irrespective of the patient’s ability to tolerate oral medication earlier than 24 hours). After parenteral artemisinin therapy, patients will receive a full course of oral ACT for 3 days. Those patients who received parenteral quinine therapy should receive: Oral Quinine 10 mg/kg body weight three times a day for 7 days (including the days when parenteral Quinine was administered) plus Doxycycline 3 mg/kg body weight once a day or Clindamycin 10 mg/kg body weight 12–hourly for 7 days (Doxycycline is contraindicated in pregnant women and children under 8 years of age) or ACT as described.

Chemoprophylaxis

Short term chemoprophylaxis (up to 6 weeks)

Doxycycline: 100 mg once daily for adults and 1.5 mg/kg once daily for children (contraindicated in children below 8 years). The drug should be started 2 days before travel and continued for 4 weeks after leaving the malarious area. It is not recommended for pregnant women and children less than 8 years.

Chemoprophylaxis for longer stay (more than 6 weeks)

Mefloquine: 250 mg weekly for adults and should be administered two weeks before, during and four weeks after exposure. Mefloquine is contraindicated in individuals with history of convulsions, neuropsychiatric problems and cardiac conditions. Therefore, necessary precautions should be taken and all should undergo screening before prescription of the drug.

Special situations

  • When parasitological diagnosis is not possible due to non–availability of either timely microscopy or RDT, suspected malaria cases will be treated with full course of chloroquine, till the results of microscopy are received. Once the parasitological diagnosis is available, appropriate treatment as per the species, is to be administered.
  • Suspect resistance if in spite of full treatment with no history of vomiting, diarrhea, patient does not respond within 72 hours, clinically and parasitologically. Such cases not responding to ACT, should be treated with oral quinine with Tetracycline/Doxycycline. These instances should be reported to concerned District Malaria /State Malaria Officer/ROHFW (Regional Office of Health and Family Welfare) for initiation of therapeutic efficacy studies.

Dr KK Aggarwal
Editor in Chief