1. the Revised Malaria Treatment Regimen 2004

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The Revised Malaria Treatment Regimen 2004Public Health & WHOand Ministry of Health & Family Welfare

Department Of Medicine

Ibn Sina Medical College

09.08.09

Objective:To update the current recommendation for diagnosis and treatment

of malaria in Bangladesh with provision for early definitive diagnosis,prompt and appropriate treatment (EDPAT) of the cases.

Background:Based on the universal principles of Early Diagnosis and Prompt

Treatment (EDPT) the National Malaria control Program in Bangladeshadopted the Treatment regimen 1994. This was done through a consensusworkshop held in BARD, Comilla in December 1994. On the basis of theevidence from various studies on drug efficacy and accessibility issuesthat are the concern of National Malaria Control Program; it has beendeemed necessary to update the Malaria Treatment Regimen and relatedoperational issues for providing treatment of all malaria cases in theendemic areas of Bangladesh with effective to ensure radical cure.

It has been evident from several studies on Monitoring of Anti-malarial drug Resistance that Chloroquine has been found to be resistantfor treatment of Plasmodium falciparum malaria to the extent rangingfrom 40%-70% in the high endemic malaria areas of Bangladesh.

The National Malaria Control Program along with all relevantpartners and collaborators arranged a consultative meeting on 13th march2004 to review and update the current malaria treatment regimen andarrived at a consensus for a Revised Malaria Treatment Regimen to beadopted n Bangladesh.

The Draft Revised Malaria Treatment Regimen was further reviewedby a technical Sub-Committee and submitted through the DirectorGeneral of Health Services, to the Ministry of Health & Family Welfare

for endorsement.

A meeting was convened under the Chairmanship of Joint Secretary,Public Health & WHO, and Ministry of Health & Family Welfare on 3rd

October 2004 for further review of the Draft Malaria Treatment Regimen.The meeting approved the new treatment regimen 2004.

Rationale for Updating the Malaria Treatment Regimen

In previous national guideline adopted in 1994 three malariaclinical case definition of Uncomplicated Malaria (UM), Treatment

Failure Malaria (TFM), & Severe Malaria (SM) were given but asCholoroquine is becoming resistant to falciparum malaria the


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The Revised Malaria Treatment Regimen 2004

treatment of UM according to1994 guideline is not acceptable atpresent situation because of chance of development of severemalaria. So for early diagnosis & effective Treatment followingclassification was adopted:

1. Uncomplicated Malaria Confirmed (UMC):

Fever or History of fever within last 48 Hours. Absence of convincing evidence of any other Febrile

illness,

High index of suspicion,

Diagnosis is confirmed by Blood Slide Examination(BSE) or Rapid Diagnostic Test (RDT) Positive forPlasmodiumfalciparum.

2. Uncomplicated Malaria Presumptive (UMP):

Fever or History of fever within last 48 Hours.

Absence of convincing evidence of any other Febrileillness,

High index of suspicion,

Non availability for confirmation: BSE/RDT. Effort should be made to confirm the case as UMC

3. Severe Malaria (SM)


With one or more of the following features of severity- A change of behavior, confusion & drowsiness,

- Altered consciousness & coma (cerebralmalaria),

- Generalized convulsion >2 episodes in 24hours,

- Hypoglycaemia (


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- Hyper parasitaemia &- Presences of asexual form of P. falciparum in

BSE or positive RDT.4. Vivax Malaria (VM)


Absence of convincing evidence of any other Febrileillness,

High index of suspicion: endemic zone, susceptibilitypopulation, Transmission season etc.

Diagnosis is confirmed by Blood Slide Examination(BSE) or Rapid Diagnostic Test (RDT) Positive forPlasmodiumvivax.

Treatment Recommendations The revised Malaria treatment regimen should be

implemented with immediate effect & universal access to treatmentto be ensured for radical cure of all malaria patients in the public &private sectors.

The National Malaria Control Programme in DGHS should takenecessary measures to adapt relevant Diagnosis & Treatment charts etc,(both English & Bangla) in line with the revised malaria treatment regimen&orient service providers accordingly. Attempts should be taken forenhancing laboratory diagnosis capability in both public & private sectors.

National Malaria Control Programme should have appropriatemechanism for regular information collection, archiving & dissemination ofinformation on Revised Malaria Treatment Regimen and should beincorporated in UMIS (Unified Management Information System).

The revised Treatment regimen for malaria is adapted for:

Early diagnosis end effective treatment of uncomplicatedmalaria

To prevent drug resistance

To reduce the mortality in severe malaria

To reduce the morbidity in severe malaria.

Revised Malaria Treatment RegimenThe Revised Malaria Treatment Regimen as per case definitionsshould be as follows:

1. Uncomplicated Malaria (UMC): The drug should be depending on the species which are as

follows:

For P. falciparum- 1st line treatment: Artemethur + Lumefantrin

combination (Coartem)- 6 divided doses over

Revised by:Md. Baha Uddin(ISMC-03):::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

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3days (Age & body weight based dose schedule isgiven in Annexure)

If for any reason Coartem cannot be given then 2nd line treatment: Quinine for 7 days.

The 1st & 2nd line treatment can be alternatively used if

there is failure of any resime.If failure occurs after use of both Quinine & Coartem

schedule or if after using Quinine for 7days Coartem can notbe used for any reason, then

3rd line treatment: Q7+T7 or Q7+D7[N.B.-1 7 days of oral Quinine will be followed by 7 days of

Tetracycline or Doxycycline in case of 2nd line treatment failure.N.B.-2 7 days of oral Quinine & 7 days of Tetracycline will be

given simultaneously in case of 1st line treatment failure].

For P. vivax malaria-

If BSE &/or RDT is positive for P. vivax then it should belabeled as P. vivax case but it should not be included inUMC. In this case-

Chloroquine 3 days + Primaquine 14 days(CQ3+PQ14).

Dose Schedule:1st day: 10 mg/kg (4 tabs for Adult);2nd day: 10 mg/kg (4 tabs for Adult);3rd day: 5 mg/kg (2 tabs for Adult).

2. Uncomplicated Malaria Presumptive (UMP):The drugs should be Chloroquine -3 days but all efforts shouldbe made for confirming the diagnosis as soon as possible byBlood Slide Examination (BSE) or RDT.

3. Severe Malaria:

Pre referral treatment: IM Quinine/Rectal Artesunate when available

should be used as pre referral treatment incommunity.

Immediate referral should be made to the nearesthealth facility where parenteral treatment isavailable.

Hospital Treatment: IV Quinine drip / IM Quinine followed by oralQuinine for upto 7 days.

Loading dose of Quinine should given. IM Artemethur / IV Artesunate can be used asalternative.

4. Malaria in Pregnant women:


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UMC:1st trimester: In case of P. falciparum infection Quinine for 7

days.2nd & 3rd trimester: In case of P. falciparum infection

Coartem.

UMP:CQ3 in all trimester but efforts should be adopted for

continuing the diagnosis as soon as possible by Blood SlideExamination or RDT.

SM: IV Quinine drip / IM Quinine followed by oral Quinine for upto

7 days.

Loading dose of Quinine should given.

IM Artemethur / IV Artesunate can be used as alternativebut preferably should not be used in 1st trimester.

Rationale for the use of other drugs available in the

market

Chloroquine: As failure is high, it should not be use in UMC cases. Fansidar: Due to drug side effects & high failure rate it should not be

used in UMC cases. Mefloquine: A highly efficacious drug for P. falciparum but is not

recommended to be used as asingle drug. Artesunate: Highly effective for P. falciparum but single drug use is

not recommended due top chance of development of resistance. Artesunate & Mefloquine Combination: Highly effective for P.

falciparum.

Implementation of treatment guideline:

1. Definitive diagnosis of malaria should be made available at thecommunity level.

2. RDT should be the method of choice for definitive diagnosis atthe community level.

3. Static health services should be use Microscopy or RDT fordefinitive diagnosis.

4. UMP should be discouraged but still to be used to prevent delayin starting the treatment.

5. All patients who have received treatment for UMP should reportto nearest health facilities for follow-up.

6. Provision of IMQ to community health workers for use as prereferral treatment in case of severe malaria. So communityhealth workers should be given training to recognize SM by

symptoms & to use pre-referral IMQ.


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7. All health care providers (Govt./Non-govt./Traditionalhealers/Quack) should be given training to us revised treatmentguideline.

8. Specific education of the patient regarding completion oftreatment should be emphasized during training for prescribers &dispensers to avoid incomplete doses ofCoartem.

9. Pregnant women in absence of effective & safechemoprophylaxis alternative method of prevention(Impregnated bed net and personal protection) should bepromoting.


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Documents

1. the Revised Malaria Treatment Regimen 2004