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STANDING INSTRUCTIONS ON PREVENTION, CONTAINMENT
AND MANAGEMENT OF MALARIA IN B.S.F. UNITS DEPLOYED IN
MALARIOUS HYPERENDEMIC ZONES
➢ There are about 3000 species of mosquito, of which about 100 are vectors of
human diseases.
➢ Mosquito has 2 stylets
➢ Mosquitoes are attracted by the body odors, carbon dioxide and heat emitted
from the animal or person.
➢ Mostly bite at dusk and dawn or in the middle of the night.
➢ 30-300 eggs/2-3 days
➢ Biting Range - Several Kms
➢ Egg to adult – 1-2 week
➢ Adult life 4-8 weeks
➢ Sporozoite –> Trophozoite –> Hypnozoite –> Merozoite –> Gametocytes –>
Oocyst
➢ Tissue schizogony (Pre RBC) – 1-4 weeks
➢ Liver-Schizogony: -The sporozoites rapidly invade liver parenchymal cells,
where they mature into liver-stage schizonts, which burst to release 2,000 to
40,000 uninucleate merozoites.
➢ RBC-Schizogony – 72 hrs in PF , 48 hrs in PV
➢ An erythrocytic stage schizont contains 10 to 36 merozoites.
➢ Mature gametocytes in Blood appear in 10-12 days in PF.
FEW PICULIARITIES ABOUT MOSQUITO & PLASMODIUM WORTH REMEMBERING
2
1- Blood Pressure:-
BP may fall due to fluid loss in sweating/Vomiting/respiration. As we
know there is high humidity in malaria months ie from May to Sep in border
area due to heavy rain & high vegetation growth. This causes increase in case
of fever, heat stroke, typhoid & dysentery.
We don’t have proper fluid for replacement while on duty as we use to
take only plain water which causes hypo osmolarity resulting in hypotension
in our body.
BP may increase due to stress induced high sympathetic outflow due to
thought of being suffering from such type of disease in remote border area.
2/3- Pulse & Temperature:-
Pulse may increase as compensatory mechanism against fluid loss & also
due to fever.
There is increase of approx. 10 beats/1degree rise of temperature. Pulse
increases up to a certain limit then it started falling down till heart becomes
unable to contract due to no filling induced non development of action
potential.
4- Respiration:-
Here we can auscultate for Breath sound/Crapts/Rhonchi/Wheeze/Chest-
pain & Respiratory rate as well.
In PF malaria breath sound may be vesicular, but if pulmonary oedema
develops, we may find crapts at lung base which sounds like tearing of paper in
addition to dyspnea.
In addition, RDS (Respiratory Distress Syndrome) develops as a result of
Metabolic (Lactic Acidosis) which is considered as the most important cause of
pathophysiology of Cerebral Malaria & Anemia.
5- Anaemia:-
Merozoites repeatedly attack RBCs causing massive hemolysis. This results
in development of anemia. Anemia leads to compromises oxygen delivery which
further leads to Lactic Acidosis & RDS (Respiratory Distress Syndrome)
6- Jaundice:-
In Malaria liver is the first organ dealing with the invasion of plasmodium.
Hepatocytes get occupied & damaged in this process resulting in raised serum
bilirubin level & development of jaundice. Also increased number of hemolysed
blood causes increased production of bilirubin resulting in jaundice.
7- Stool:-
Stool may be loose due to hyper sympathetic stage or due to ileitis/colitis
following entrapment of PF Rosettes in small ileac-colic capillaries.
3
8- Urine:-
Firstly, urine becomes yellow due to excess bilirubin secreted by the damaged
hepatocytes. This may occur within 1 week of mosquito bite. Then the urine
becomes coffee red color due to dissolution of starting volume of hemolysed RBC
in urine. Now as further RBC hemolysis takes place urine becomes Red in color
with clot at the bottom on the container. Glomerular cell doesn’t cope up with the
increased load of hemolysed RBC resulting in increase of blood urea. Also, some
glomerulus gets damaged due to these increased macromolecules causing nephritis.
9- Vomiting
3- factors work behind excessive vomiting in PF. Firstly due to excessive
sympathetic tone of being suffering from PF, there is increased acid secretion in
stomach which irritates the stomach for vomiting. Secondly PF also increases high
acid output by inducing proton pump & lastly all control centers of brain set on
high frequency signals as feedback stimulation of the Hypothalamus against PF
induced hypoglycemia due to high threshold set up of higher commands in high
fever CTZ gets stimulated as error resulting in increased acid release in stomach
which induces vomiting.
10- Pain abd/Dyspepsia:-
Due to entrapment of PF rosettes in intestinal capillaries a generalized ileitis
like situation develops which is further added by high acid & pepsin. As rosettes
may get entangled at any site there may be ischemia of pancreas, appendix, and
kidney in addition to ileitis.
11- Headache:-
As the vascularity of any part of brain may be blocked due to PF rosettes that
part produces ischemic pain (headache). Also, all control centers of brain set on
high frequency signals as feedback stimulation of the system against PF induced
hypoglycemia; there is increased requirement of glucose which further induces
ischemic pain.
12- Convulsion/Coma/Death: -
Seizure is induced due to hypoglycemia. PF reduces blood sugar by utilizing
human blood sugar. High urea may create a situation like uremia & coma & finally
death.
13- Metabolic Acidosis (predominantly lactic acidosis)
It has been now recognized as a principal pathophysiological feature of
severe manifestations of PF malaria like cerebral malaria and severe anemia. It is
the single most important determinant of survival and can lead to Respiratory
Distress Syndrome. Lactic acidosis has been identified as an important cause of
death in severe malaria.
Lactic acidosis in severe malaria has been attributed to several causes:
• Increased production of lactic acid by parasites (through direct stimulation by
cytokines)
4
• Decreased clearance by the liver.
• Most importantly the combined effects of several factors that reduce oxygen delivery
to tissues
o Marked reductions in the deformability of uninfected RBCs may
compromise blood flow through tissues
o Dehydration and hypovolemia can exacerbate microvascular obstruction by
reducing perfusion pressure
o Destruction of RBCs and anemia further compromises oxygen delivery.
Treatment
Type of
Malaria
Drug Duration Purpose
PF 1) Inj Artisunate – 00 – 00 – 0
2) Tab Lumither forte (ACT) 0-0-0-0-0-0
3) Tab Artisunate/Inj Arteether/Inj
Artemether
4) Tab PQ
2 ½ days
3 days
3 days
45 mg
Load reducer
Main drug
Tailing
2nd day & 24 hrs
after tailing stat
PV Tab Larinate kit (Artisunate + SP)
Tab Artisunate 200 mg
Tab PQ
3 days
3 days
45 mg
Main drug
Tailing
45 mg 2nd day & 24
hrs after tailing 15
mg x 14 days
Mix
(PF+PV)
1) Inj Artisunate – 00 – 00 – 0
2) Tab Lumither forte (ACT) 0-0-0-0-0-0
3) Tab Artisunate/Inj Arteether/Inj
Artemether
4) Tab PQ
2 ½ days
4days
3 days
45 mg
Load reducer
Main drug
Tailing
2nd day & 24 hrs
after tailing x 14
days
CM Tab Lumither Forte 0-0-0-0-0-0
Tab PQ 45 mg
4 days
Stat
Main drug
24 hrs after L/F
Note “The Nalkata Syndrome” which
comprises Heatstroke, Gastroenteritis,
Typhoid along with Malaria.
1- Inj Ceftriaxone 3-5 days
2- Inj Metron
3- IV fluid in addition to
ACT-AL regime
5
ANTIMALARIAL DRUGS WITH DOSE SCHEDULE
Type of
malaria
Medicine 1st day 2nd day 3rd day
PF Ex-NE
region
ACT-SP Artisunate(200
mg) + SP(75) mg
Artisunate (200
mg)
Artisunate (200
mg)
PQ (After meal) 45 mg stat
PF NE
region
ACT-AL Artisunate 2.4 mg/kg
IV/IM, or
2 vials (=120
mg) x BD
2 vials (=120 mg) ACT-AL (80/480) BD
dose x 3 days
Artimether 3.2 mg/kg IM,
or
Artimether 3.2
mg/kg IM
Artimether 3.2
mg/kg IM
Artimether 3.2
mg/kg IM
Arteether 150 mg IM 150mg IM 150mg IM 150mg IM
PQ (After meal) 45 mg stat
ACT-AL (80/480) 3rd day onward in BD dose x 3 days
(Plane Tab Artisunate may be extended up to symptoms
persist)
PV/Mix Tab CQ (150 mg base) 600 mg 600 mg 300 mg
PQ (After meal) x 14 days 15 mg 15 mg 15 mg….14 days
Other Supportive Medicines Inj Ceftriaxone 1 gm IV BD x 5 days
Inj Pan 40 –IV or Tab Ranitidine BD till end of
Antimalarial drug
Syp Sorbiline -BD
Tab PCM -SOS
IV Fluid
Note Inj Quinine Di Hydrochloride kept as reserve drug
1. PROTECTION FROM MOSQUITO BITES WHILE ON DUTY OR OUTDOORS:-
➢ ALL TROOP PERSONNEL ARE TO WEAR THEIR SHIRT SLEEVES ROLLED DOWN.
➢ EVERY PERSON SHOULD PROTECT THEIR FACES WITH FACE MASK BOTH DURING DAY
AND NIGHT WHILE ON DUTY (IF VISIBILITY PROBLEMS AT NIGHT IS CAUSED BY FACE
MASK, THEY SHOULD USE A SCARF AROUND THEIR NECKS AND APPLY REPELLANT
CREAM ON THEIR FACE)
➢ GLOVES SHOULD BE WORN DURING NIGHT DUTIES ESPECIALLY WHEREAS
REPELLANT CREAMS CAN BE APPLIED DURING DAY DUTIES
➢ ADHERANCE TO THESE PRECAUTIONS SHOULD BE PHYSICALLY CHECKED BY THE
DUTY SUPERVISORY STAFF WHO SHOULD BE MADE ACCOUNTABLE FOR LAPSES IF
NOTICED BY ANY SENIOR MEMBER ON PERIODIC RANDOM CROSS-CHECKING AS IS
DONE WITH CHECKING OF GUARD DUTIES.
2. PROTECTION FROM MOSQUITO BITES WHILE NOT ON DUTY OR INDOORS:-
➢ DDT SPRAY INDOORS IRRESPECTIVE OF THE TYPE OF STRUCTURE SHOULD BE
STRICTLY ADHERED AND SUPERVISED BY TRAINED BSF PERSONNEL TO AS PER THE
STATES SPRAY SCHEDULE -Appx – ‘A’
6
➢ MOSUITO NETS SHOULD BE IMPREGNATED WITH INSECTICIDES @10ML 0F 2.5
%DELTAMETHRINE IN 500 MI WATER/ NET SEPARATELY AND SPREAD OUT FLAT ON
BEDS TO DRY ON A 4 MONTHLY CYCLE (THE DRIPPING SOLUTION HAS AN ADDED
ADVANTAGE OF KILLING OTHER BLOOD SUCKING ARTHROPODS). Appx – ‘B’ ➢ ALL NETS SHOULD BE CHECKED PERIODICALLY FOR TEARS WHICH SHOUD BE
MENDED IMMEDIATELY. ➢ REGISTER SHOULD BE MAINTAINED SHOWING DATE OF IMPREGNATION AND DUE
DATES WHICH SHOULD BE PUT UP TO THE COY COMMANDER EVERY MONTH AND TO VISITING OFFICERS AT ALL COY LEVELS.
➢ INDIVIDUALS PROCEEDING ON LEAVE DURING THIS PERIOD SHOULD GET THIS PROCEDURE COMPLETED WHICH SHOULD BE ENDORSED ON THEIR CLEARANCE CERTIFICATE AND SAME TO BE ADOPTED IF INDIVIDUALS ARE RETURNING TO DUTY PLACE DURING THAT PERIOD.
( However, troops should be encouraged to purchase long lasting impregnated nets which has a shelf life of 4-5 years even after washing and also has an added advantage of repellant effect).
DAMAGED SCREEN PROOFING SHOULD BE TAKEN CARE OF THROUGH OUT THE YEAR
(THE BARRACK COMMANDERS SHOULD BE MADE ACCOUNTABLE FOR ANY
LAPSES FOUND IN LIVING BARRACKS).
3. FOGGING: -
FOGGING SHOULD BE CARRIED OUT MORNING AND EVENING AND A LOG BOOK
MAINTAINED SHOWING THE TIME AND DURATION OF ITS OPERATION TO BE SIGNED
BY PC/CC ON A DAILY BASIS
King Fog Liquid (L) Diesel (L) Area (Hectare ie M2)
Indoor 50 10 1000
Outdoor 200 ml 250 ml 1000
4. SOURCE REDUCTION:-
➢ DRY DAY ONCE A WEEK IS TO BE STRICTLY FOLLOWED ON FRIDAYS FOR FILLING UP
DITCHES, DRAINING NATURAL PITS AND EXFOLIATION OF BUSHES AND SHRUBS
AROUND THE PERIMETER OF THE LOCATION OF BOP’S.
➢ LARVIVOROUS FISH AVAILABLE AT NEAREST MOTHER HATCHERY SHOULD BE
FETCHED AND INTRODUCED INTO WATER BODIES WITHIN 500 YDs OF THE LOCATION
OF THE POSTS.
5. CHEMOPROPHYLAXIS:-
HAS BEEN STOPPED AND IF IT HAS TO BE RESTARTED, SEPARATE INSTRUCTION TO
THE EFFECT WILL BE ISSUED SEPARATELY.
6. MICROSCOPY AND PREVENTIVE SCREENING (MODIFIED QUARANTINE):-
SLIDE EXAMINATION FOR MALARIA PARASITE HAS BEEN DECENTRALISED AND
MINIMUM THREE BLOOD EXAMINATIONS WITH THE LAST EXAMINATION AT THE
7
UNIT HQr BE CARRIED OUT WHEN INDIVIDUALS PROCEEDS ON LEAVE/T.D ETC
WITHIN 10 DAYS OF DEPARTURE AND FINDINGS RECORDED IN THE QUARANTINE
REGISTER.(ONLY ON EXTREME EMERGENCIES ONE TEST AT THE HOSPITAL CAN BE
CONSIDERED AFTER IT IS CERTIFIED BY THE ADJUTANT AS GENUINE, HOWEVER IN
SUCH CIRCUMSTANCES NOTE SHOULD BE MADE IN THE REGISTER AND THE
INDIVIDUAL SHOULD BE EXPLAINED TO SEEK MEDICAL ADVICE AT THE EARLIEST ON
FEELING UNWELL AT HIS DESTINATION).
It is suggested that when individuals are proceeding away from endemic malaria zones, it would be
prudent to get the individuals in question be tested for malaria parasite microscopically before
departure and test their blood for MP at their destination at intervals of 4 days up to 2 Wks (the last
test to be on the 14th day after departure from malaria endemic zone) or on feeling unwell during
this period i.e incubation period so that it can indicate the place of infection especially if not on
chemoprophylaxis for malaria.
7. AWARENESS:-
MEDICAL OFFICERS DURING THEIR VISIT TO BOPS SHOULD MAKE THE TROOPS AWARE
OF MALARIA, ITS PREVENTION AND PRACTICES THAT ARE TO BE FOLLOWED AND
RECORDS OF THESE SESSIONS BE MAINTAINED.
8. MALARIA CARDS:-
TROOP PERSONNEL MOVING OUT OF THE UNIT SHOULD BE IN POSESSION OF MALARIA
CARDS, THE SAMPLE COPY OF WHICH HAS ALREADY BEEN CIRCULATED TO ALL
FRONTIERS/ UNITS CONCERNED AS AMMENDED FROM TIME TO TIME.
9. MALARIA KIT:-
MEDICINES PROVIDED IN THE MALARIA KIT SHOULD BE COLOUR CODED SINCE IT HAS
BEEN OBSERVED AND ALSO REPORTED BY DOCTORS ATTENDING THE ‘ ORIENTATION
PROGRAMME ON MALARIA PREVENTION’ AT MALARIA CELL ( CH BSF AGARTALA)
THAT TROOP PERSONNEL DO NOT BOTHER TO KNOW OR ARE UNAWARE OF WHAT &
WHEN AND HOW THE MEDICATIONS ARE USED. TELEPHONIC CALLS ARE ALSO BEING
RECEIVED BY PATENTS IN REMOTE VILLAGES WHO FALL SICK AND SEEK ADVICE
SINCE THEIR IS NO PROPER HEALTH FACILITY IN THE NEAR VICINITY OF THEIR
RESIDENCE. IT BECOMES DIFFICULT TO PROVIDE ADVICE SOMETIMES SINCE THE
PATIENTS ARE NOT ABLE TO READ DUE TO EITHER SMALL PRINT OR THEIR FAMILY
MEMBERS ARE NOT LITERATE ENOUGH.
IT IS FELT A COLOUR CODING SYSTEM IS TO BE ADOPTED FOR THE KIT AS ABOVE AND
PACKED IN INDIVIDUAL ENVELOPES WITH COLOURED STICKING TAPE.
WHILE HANDING OVER THE KITS THE INDIVIDUAL IS TO BE EXPLAINED BY N/ASTT
ABOUT THE USE OF THE CARD & KIT AT THE POINT OF ISSUE DEPENDING ON THE
CONTENTS OF THE KIT.
RED ARTETHER BLUE ACT (ASP) ORANGE QUININE
YELLOW ARTEMETHER BLACK ACT(ALT) GREY VOMISTOP
GREEN ARTESUNATE WHITE PARACETAMOL RUST RANITIDIN
8
A SYSTEM OF CHECK SHOULD BE MAINTAINED AT GD OFFICE AS WELL SO THAT A
CROSS CHECKING OF THE AWARENESS CAN ALSO BE CARRIED OUT.
10. SIGNAGES: -
a) Pf-MALARIA ZONES AND REMINDER OF PROTECTION AGAINST MOSQUITO BITES
SHOULD BE PLACED AT VANTAGE POINTS. (APPX-‘C’)
b) SIGNS OF MALARIA AND RECOGNITION OF IMPENDING PROGRESS TO SEVERITY
SHOULD BE DISPLAYED IN ADVANCED FIRST AID POSTS IN THE COYS AND IN THE
EMERGENCY ROOM OF THE HOSPITAL. (APPX-‘D’)
c) TREATMENT AND REFERAL PROTOCOL AT UNIT HOSPITAL SHOULD BE DISPLYED IN
THE EMERGENCY ROOM.(QUININE SHIULD BE USED IN HOSPITAL SETTINGS WITH
FREQUENT GLUCOCHECK ,ORAL ACT IN BOP’S, INJ ARTESUNATE AT BOP’S WHERE THE
TERRAIN IS DIFFICULT.HOWEVER IN ALL CASES IF TEST IS POSITIVE FOR MALARIA BY
KIT OR MICROSCOPY AND FEVER LYSIS DOES NOT OCCUR WITHIN 24 HRS EVACUATION
BY ANY MEANS AVAILABLE SHOULD BE EFFECTED.(APPX-‘E’)
d) ABC PROCEDURES AT EMERGENCY ROOMS AND FIRST AID POSTS ALSO REQUIRES TO
BE DISPLAYED. (APPX-‘F’)
e) EVACUATION PROTOCOL SHOULD BE CHALKED OUT DEPENDING ON THE AOR OF
THE UNIT WITH SPECIFIC INSTRUCTIONS REGARDING THE EVACUATION TO NEAREST
HEALTH FACILITY FOR EACH COY IN CASES OF EMERGENCIES.
11. VETTING: -
ALL CASES SUSPECTED TO HAVE MALARIA AND ENDED FATALY SHOULD BE
SUBJECTED TO POST-MORTEM EXAMINATION IF ALL TESTS FOR MALARIA RDT,
MICROSCOPY, QBC ARE NEGATIVE AND A COPY OF THE COI SHOULD BE SENT TO
MALARIA CELL FOR VETTING. ALL CASES OF DEATH SUSPECTED/PROVEN DUE TO
MALARIA SHOULD ALSO BE INVESTIGATED AND RESULTS OF THE MANAGEMENT
ENTERED IN THE PROFORMA BY MEDICAL OFFICER ONLY. (APPX-‘G’)
12. PHARMACOVIGILANCE: -
DISTURBING REPORTS OF DELAYED PARASITIC CLEARANCE TO SOME ARTEMISININE
DERIVATIVES HAVE RECENTLY BEEN REPORTED AND INVESTIGATION IS IN PROGRESS
BY MALARIA RESEARCH CENTRE.IT THEREFORE BECOMES MANDATORY TO INFORM
ADVERSE OUTCOME OF THE DRUGS USED FOR TREATING MALARIA, IN THE PROPER
PROFORMA TO THE DISTRICT/STATE PHARMACOVIGILANCE OFFICER. (APPX-‘H’)
13. MALARIA MONTH: -
THE MONTH OF JUNE IS OBSERVED AS MALARIA MONTH HENCE ALL
PREPARATION FOR THE NEXT MALARIA SEASON SHOULD BE COMPLETED BY 31ST
MAY LIKE MAINTENANCE OF FOGGING MACHINE, 100% IMPREGNATION OF BED
NETS STOCKING OF ANTI MALARIAL DRUGS, AND RD KITS AND COMPLETION OF
INDOOR RESIDUAL SPRAY SCHEDULE.
9
14. HEALTH COMMITTEE: -
A UNIT WISE HEALTH COMMITTEE MAY BE CONSTITUTED AT UNIT LEVEL CONSISTING
OF: -
PO: - COMMANDANT, MEMBER – 1. MEDICAL OFFICER, MEMBER – 2. QUARTER MASTER/
ADJUTANT, MEMBER – 3. SM/SI (LINE OFFICER), MEMBER – 4. SANITATION NCO SO THAT
THE DISEASE PROFILE OF THE UNIT, NOT ONLY OF MALARIA BUT OTHER
COMMUNICABLE AND NON-COMMUNICABLE DISEASES CAN BE STUDIED AND
TARGETED INTERVENTION MODALITIES CAN BE PLANNED SO THAT PROPER
IMPLEMENTATION OF HEALTH-RELATED ACTIVITIES CAN BE UTILISED IN TERMS OF
MEN, MATERIAL MONEY AND TIME WITH-IN AVAILABLE RESOURCES. A QUARERLY
REPORT ON PROBLEMS DETECTED, REMEDIAL ACTION TAKEN AND OUTCOME SHOULD
BE PREFERRED TO FRONTIER HEADQUARTER FOR PERUSAL OF COMPETENT
AUTHORITY.IF THER IS A VACANCY OF MEDICAL OFFICER IN THE UNIT ,A REQUEST
SHOULD BE MADE TO SECTOR DIG TO DEPUTE A MEDICAL OFFICER FOR THE MEETING
WHO SHALL AFTER GOING THROUGH THE HOSPITAL DATA PARTICIPATE IN THE
DISCUSSIONS.
15. TELEMONITORING: - TO CONTINUE AS PER PRESENT PRACTICE.
Da
te
Nam
e
Inv
Tim
e
Sign – Symptom -Treatment
B Blood
Pressure
P Pulse
T Temp
S Stool
Urine
In/Ou
t
V Vomitn
g
A Ane
mia
J
Jaundic
e
C Che
st
C CVS
H Headche
C Convln
Comma
Tre
atm
en
t
20-1
2-0
9
Ct
Kas
hav
Das
PF
+v
e
6A
M
138/82 94
10
2 C
hil
l S
wea
tin
g 24
clear Red 1000/8
50
++ - ++ ++ - ++ - Inj
Artisunate
00-00-0 Tab
Random-D Glucose
6 P
M
130/80 84 100 22 - + - - + - + - CST
Note: - A SYSTEM OF MONITORING OF FRESH CASES FROM 6AM-6AM DAILY SHOULD BE PUT
IN PLACE SO THAT EPIDEMIC WARNING AND RESPONSE CAN BE ACTIVATED AT THE
EARLIEST IN BOP SHOWING A SUDDEN SPURT OF TRANSMISSION (MASS SCREENING AND
TREATMENT, ADDITIONAL ROUND OF SPRAY, MINOR HEALTH ENGINEERING ACTIVITIES,
EXFOLIATION ETC) (Appx-J)
10
11
RESTRICTED
(MALARIA CARD) TO BE SHOWN TO A DOCTOR IN CASE OF ILLNESS
DURING MOVEMENT / LEAVE OF THE SERVING ARMED FORCE PERSONNEL.
No……………Rank………Name………………………………………………….of …. Bn
Battalion BSF, Tripura, is deployed on operational duties in the HYPERENDEMIC MALARIAL
ZONE OF TRIPURA STATE. In case individual falls sick during movement or on leave, the
following factors may please be considered by the attending Medical Practitioner during treatment.
1. The zone of his duty is critically Mosquito infested which carry CHLOROQUINE
RESISTANT P. FALCIPARUM AND P. VIVEX strains.
2. In almost all cases, these are severe parasitemia including mixed infection by P.
FALCIPARUM & P. VIVEX WHICH OFTEN CAUSE CEREBRAL MALARIA.
3. Thus, the following treatment is successfully tried for sign of patients and may be given to
the individual in case he shows signs/ symptoms of malaria as below.
➢ Fever (with or without chill and rigor)
➢ Persistent headache, rigidity of neck.
➢ Perturbation, Mental Instability/Violence
➢ Vomiting, Dark Red Urine. Unconsciousness.
TREATMENT FOLLOW UP MONITOR
NB: If the Individual becomes unconscious (With or Without Fever), it is possible that this is
due to CEREBRAL MALARIA. In this case kindly admit him in any good hospital and show this
card to hospital authorities. Also, kindly intimate to his home and Unit in the following addresses.
Home Address
Unit Medical Officer
C/O Shri………………………… ……..BN B.S.F.
Vill/ Steet……………………… Address for Correspondence
PO……………………………. Commandant , ……..BN BSF
P.S…………………………… _____________, P.O ________
Dist………………………….. Dist- __________, State _______
PH No- …………………. PH No- ………………….
Date Name Inv Symptoms
Treatment B P T R A J S U V P H C
20-12-
09
Ct
Kashav
Das
PF
+ve 5
AM
138/82 94 102 24 - ++ - Red ++ - ++ - Inj Artisunate 00-00-0 BD
Tab Lumither Forte BD
Tab Rantac BD
Tab PCM SOS
IV drip / Oral Glucose
5
PM
130/80 84 100 22 - + - - + - + -
RED ARTETHER BLUE ACT (ASP) ORANGE QUININE
YELLOW ARTEMETHER BLACK ACT(ALT) GREY VOMISTOP
GREEN ARTESUNATE WHITE PARACETAMOL RUST RANITIDIN
If Malaria found Negative on Slide/Kit & the patients with signs of Severe Malaria,
don’t hesitate, Start Inj Artisunate / Tab ACT (Lumither Forte) immediately, it’s safe,
delay in start may endanger patient’s life
12
APPX ‘A’
DDT SPRAY
1. Stirrup pump/back up -02
2. Spare nozzle tip for pump -01
3. Bucket 15 litters -04
4. Bucket 5/10 litters -01
5. Asbestos thread -03 Mtrs
6. Pump washers -02
7. Measuring mug -01
8. Straining cloth -01 Mtr
9. Plastic sheet 3X3 Mtr -01
10. Soap -01
Manpower:-
Each spray squad consists of:-
1. Supervisor -01 (To look after and keep records)
AT LEAST ONE BSF PERSON FROM EACH COY SHOULD KNOW SUPERVISION OF
SPRAY OPERATIONS AND CAN BE TRAINED LOCALLY OR THROUGH CIVIL
AUTHORITIES SINCE THE CIVIL SUPERVISOR IS MORE OFTEN THAN NOT
AVAILABLE WITH THE WORKERS.
2. Filed worker -05
(Pump man and spray man on each pump and man for bringing water and to prepare suspension for
both pumps).
Technique
1. Nozzle tip preferably of stainless steel and should be flat fan type.
2. Discharge rate -740 to 850 ML per minute
3. Distance of nozzle from wall – 45 CM
4. Area to be covered – 150 sq Mtrs in five minutes.
5. To obtain the above discharge rate, the pump man should give 20 to 26 strokes per minute
with 10 to 15 CM Plunger movement at a pressure of 10 P S I at the nozzle tip.
6. Spray direction: - Vertical from top to bottom and bottom to top with 21” width.
7. Overlapping:- 3” of preceding swath
8. Dose: - DDT 50% WP 1 Kg per 10 Ltr of water to cover 500 sq Mtrs of area.
Procedure:-
1. Take 1 kg of DDT 50% WP and mixed it in 10 Ltr of water to make milk like a solution
2. Take small quantity of water , mix the desired amount of DDT & mix properly to form a paste
3. Fill the requisite amount of water in the bucket to form a solution
4. Strain the solution though a piece of cloth
5. Start spraying with vertical direction from top to bottom and vice versa with over lapping 3 Inch
of the preceding and keeping in view all techniques mentioned above.
6. The spray should be uniform and the deposit should be in small discrete droplets
7. All sprayable surfaces like walls, ceiling back side of doors, under surface of the furniture inside
the room and also the corners of the room should be covered.
8. Naka/OP paints should also be sprayed inside.
9. If the ceiling is thatched, the ceiling should be two coats starting from opposite direction.
10. If the house is built on platforms the under surface should also be sprayed.
11. Spray the inside of the house first and then the outside only under the eaves (chajja)
12. Cattle shed should not be sprayed.
13. Spray should not be done from opposite direction of wind.
13
14. Contamination of food material and drinking water should be avoided in the house by covering those
before spraying.
15. The spray man should protect himself by protective clothing.
16. Local drinking water source should not be polluted when spray equipment are cleaned
17. Maintain the record of spraying.
14
APPX ‘B’
IMPREGNATION OF MOSQUITO NET
Quality of bed nets/ choice of bet nets:-
Nylon nets are preferred than cotton nets because these are more durable, quicker in drying after
impregnation and insecticide stays longer on the surface of the nylon fiber.
Dosage:-
Dose of deltamethrin is 25 mg per sq. meter. That means 1 gm of deltamethrin 2.5% required per sq
meter.
Standard size of mosquito net is about 10 sq meters. Hence 10 ml of deltamethrin 2.5% is required for one
mosquito net.
Required materials:-
1. Deltamethrin Liquid - 2.5%
2. Measuring tube
3. Water for solution
4. Basin / Bucket
5. Hand gloves
6. Face Mask.
Procedure:-
1. All precaution methods should be taken for self-protection using gloves and face mask.
2. Mix 10 Ml of deltamethrin 2.5% with 500 Ml of water for single-bed net &
3. Mix 15 Ml of deltamethrin 2.5% with 750 Ml of water for double-bed net in a basin and make a
solution.
4. Fold the mosquito net to such a width which can be held with both closed hands to roll forward.
5. Roll the folded mosquito net forward in the solution up to last end, then roll it backward so that inner
and upper side will become wet with the solution.
6. After impregnation, dry the net in the shade spread out on the cots or plastic sheets (where-ever
applicable), the dripping solution from the net has an added advantage of killing other blood sucking
arthropods.
7. After drying the net is ready to be used.
8. Each mosquito net should be impregnated separately for correct strength of insecticide.
9. After completion of impregnation, the person impregnating should wash his hands with soap.
10. Residual efficacy:-
If the mosquito net is not washed, the net will have efficacy for six months, but if the mosquito net
is washed within six months it will require re-impregnation.
15
APPX ‘C’
YOU ARE ENTERING
“MALARIA PRONE ZONE”
1. PLEASE ROLL DOWN YOUR
SLEEVES
2. USE MOSQUITO REPELLENT
CREAM ON UNCOVERED PARTS
OF YOUR BODY.
16
APPX ‘D’
HOW TO RECOGNISE THE DANGER SIGNS
1. ASK
• ‘SAB’ thik hai? (All is well?)
➢ S -Sleep (Do you sleep well?)
➢ A -Appetite (Do you eat well?)
➢ B –Bowel evacuation (Do you void well?)
Derangement of any factor of ‘SAB’ is external manifestation of internal
mental & Physical status of individual.
• Is the patient unable to drink?
• Has the patient had fits?
• Does the patient vomit repeatedly?
• How much urine does the patient pass? No urine? Very little? Dark
urine?
2. LOOK
• Is the patient abnormally sleepy, difficult to wake or confused?
• Does the patient have pallor?
• Does the patient have dehydration?
• Is the patient unable to stand or sit?
*IF THE ANSWER TO ANY OF THESE IS YES, THE PATIENT HAS
SEVERE FEBRILE DISEASE PROBABLY IMPENDING PROGRESS
TOWARDS SEVERE MALARIA. THE PATIENTS’ LIFE IS IN
DANGER. URGENT TREATMENT IS NEEDED AT A CLINIC OR
HOSPITAL TO SAVE THE PATIENTS LIFE
17
APPX ‘E’
TREATMENT AND REFERRAL PROTOCOL
Clinical suspicion of severe malaria
Look for danger signs
Blood test positive for P Falciparum
Blood test for malaria
Given Artemisinin derivative
(Injection / suppository) or
quinine
Pregnancy/postpartum
Women/child ‹5 yrs age
Consider Referral if facilities not
available in small hospital
Convulsions
Unconscious
ABC coma
Management
Start IV Fluid
Scanty Urine Severe Anaemia
Respiratory
Distress
Shock
IV fluid Urethral catheterization
Anticonvulsant
IV Line
Recurrence
Oxygenation
For Blood
Transfusion No
Improvement Improvement
in Output
Continue Treatment
Antibiotics,
Fluids,
Inotropic
No
Improvement
Restrict
IV
Oxygenation
Refer to Higher Centre
18
CAB Management
The priorities of first aid are…
C -CIRCULATION
A -AIRWAY
B -BREATHING
.
C -Circulation
Check for circulation (to see if the heart is still beating) by feeling for the Adam’s apple (lump
on the windpipe) with two fingers. Slide the fingers to the side of the windpipe and feel for the
pulse. If the heart has stopped beating use chest compression to try to restart the heart. Place
your hand flat just above the point where the ribs meet the breastbone. Bring the other hand
on top of it and lock your fingers together. With your arms straight, press down firmly on the
breastbone, pushing it down by 4–5 cm. Release the pressure and repeat the compressions at a
rate of about 80 per minute. If the person is also not breathing, alternate 15 compressions with
two breaths until help arrives.
A -Airway
The airway of an unconscious person may be narrowed or blocked, making breathing difficult
and noisy or impossible. This happens when the tongue drops back and blocks the throat.
Lifting the chin and tilting the head back lifts the tongue away from the entrance to the air
passage. Place two fingers under the point of the person’s chin and lift the jaw, while placing
your other hand on the forehead and tilting the head well back. If you think the neck may be
injured, tilt the head very carefully, just enough to open the airway.
B -Breathing
19
Check for breathing by placing your head near the person’s nose and mouth. Feel for breath
on your cheek or moisture on the back of your hand.
If a person has just stopped breathing use mouth to mouth ventilation. Make sure the airway
is open and head tilted back. Pinch the nostrils together, take a deep breath and blow into the
mouth, firmly sealing your lips around the mouth so air is not lost. You should see the chest
rise.
Remove your lips and let the chest fall. Continue this, giving about ten breaths every minute
until help arrives or breathing begins.
The Recovery Position
This is the best position for an unconscious person or someone having a fit. It allows them to
breathe easily and prevents them from choking. After checking the ABC, bend the nearest arm
to you, putting the hand by the head. Then bring the far arm across the chest and hold both
hands in one of yours. With your other hand pull the furthest leg up at the knee and roll the
person towards you to lie in this position.
LEFT LATERAL POSITION
• First things first
• In an emergency any number of things may need your attention at the same time. If you try
to do everything at once you may easily get distracted from the essential matters.
• An unconscious person always takes priority and needs immediate help to make sure he or
she can breathe.
20
21
APPX ‘G’
INVESTIGATION REPORT ON DEATH DUE TO MALARIA
1. Basic Information :
1.1 Date of death :
Time of death :
1.2 Regt No. & Name of the deceased :
1.3 Age :
1.4 Sex :
1.5 Address (Usual place of residence) :
1.6 Occupation of the deceased :
2. Case history of illness :
2.1 Source of information :
> Paramedical staff (specify the designation)
> Treating physician (Specify the qualification)
> Any other (Specify)
2.2 Date and hour of onset of illness :
2.2.1 Total days of illness :
2.3 Sign and symptoms at the time of onset of the illness:
Fever intermittent /Fever continues/ Rigor/ Headache/ Diarrhea/ Vomiting/ Blood in stools /
suppression of urination/ Abnormal behavior /Convulsions /Blurring of vision /Unconsciousness
(Tick mark those present)
Others (Specify)
2.4 Place where disease started
> a) Usual place of residence : Yes/ No
> b) If no, give address :
2.5 History of movement / specify halting station(s) proceeding 3 weeks from the date
of onset of illness.
a) Date of departure from residence.
b) During first week
c) During second week
d) During third week
2.6 Referred to Hospital /PHC/Dispensary : Yes/ No
(Tick mark whichever is applicable)
2.6.1 Referred or advised by self/ family member/Medical Officer
(Tick whichever is applicable)
2.6.2 Date of reference :
The investigation should be carried out by Medical Officer. Any Investigation carried out by a
person other than Medical officer will not be valid
22
2.6.3 Name of the medical institution where referred :
3. Parasitological investigation and treatment :
3.1 Blood smear examination and treatment before hospital admission
3.1.1 Date of blood slide collection / Rapid Diagnostic test:
3.1.2 Date of presumptive treatment given
Name of Drug Dose
1.
2.
3.1.3 Blood slide collection (or Rapid test carried out) by :
3.1.4 Date of blood slide examination/ Rapid test :
3.1.5 Name of laboratory where examined :
3.1.6 Name of the technician :
3.1.7 Result : Species: Stage (in case of slide)
3.2 Parasitological investigations and treatment after admission to hospital :
3.2.1 FOR EACH BLOOD SMEAR COLLECTED / RAPID TEST DONE
S/No. Collection Examination Results
Date Time Date Time Positive Species Stage Density ,(If
counted)
1
2
3
4
FOR EACH BLOOD SMEAR RE-EXMINED (NOT FOR RAPID TEST)
S/No. Collection Examination Results
Date Time Date Time Positive Species Stage Density ,(If
counted)
1
2
3
4
(* Pers 100 fields of thick smear)
3.2.2 Other Biochemical / Pathological investigations done (Specify)
3.2.3 History of case on admission to Hospital
3.2.4 Source of information & details : Treating physician /Case history sheet.
3.2.5 Date of referral _____________ and by whom ____________________________
3.2.6 Date and time of admission
3.2.7 Name of treating physician (s) and qualification
1. 2.
3.2.8 Date and time of first examination by physician.
3.2.9 Sign/Symptoms observed / recorded in case sheet.
23
Fever intermittent/ Fever continues /Rigor/ Headache / Diarrhea / Vomiting /Blood in stools /
suppression of urination /Abnormal behavior / convulsions /Blurring of vision/ Unconsciousness / any other
(Specify)
3.2.10 Tentative Diagnosis.
3.2.11 Confirmation of diagnosis by microscopy /Rapid test
(Vide item No. 3.2.1)
Date: Time:
3.2.12 Clinical progress of the case
Treatment
a) Antimalarials
Date Drug Dose
1.
2.
3.
4.
b) Other supportive treatment
Date Drug Dose
1.
2.
3.
3.2.13 Evaluation of clinical progress (date wise)
4. Death: Date Time
4.1 Cause of death in microscopically confirmed cases of malaria
(Use international certificate proforma)
1.
2.
3.
4.2 Cause of death in clinically suspected case of Malaria
4.3
Sign/ Symptoms present During different diagnosis
In the deceased Following were excluded
(Tick mark were necessary)
- Coma Diabetes, head injury, hepatic, any other
conditions.
24
- Hyperpyrexia Heat stroke, viral infection and septicemia
due to U.T. infection etc.
- Convulsions Other conditions
- Shock / collapse Other causes of shock and collapse
- Pulmonary oedema Cardiac/ respiratory tract conditions.
- Haemoglubinurea/ Kidney, bladder lesions
- Oliguria Kidney dysfunction due to other diseases
- Diarrhea/ dysentery Acute intestinal infection, cholera,
Gastroenteritis, bacterial dysentery.
5. Post mortem details, if undertaken
(Official Seal) Medical Officer
Designation __________
Date __________
25
APPX ‘H’
SUSPECT ADVERSE DRUG REACTION REPORT FORM
Serious Adverse Drug Reaction Identification No. ...................................................................................................................................................
PATIENT INFORMATION
Name .................................................................................. Age ......................... Date of birth (Day/Month/Year): .......... / .......... /..........
Sex M F
Patient’s address: ................................................................................................................................................................................................................................................
............................................................................................................................. ...................................................................................................................
If female, is the patient pregnant?
Yes – if yes: date of last menstrual period ......... / .......... /.......... No Not sure
Weight......................... kg Height......................... m
NATURE OF ADVERSE EVENT (cross those that apply)
Death Life-threatening Hospitalization Permanent disability Congenital anomaly
Other: (specify)..........................................................................................................................................................................................................
DATE OF OCCURRENCE (Day/Month/Year): ......... / .......... /..........
DESCRIBE THE ADVERSE EVENT IN DETAIL (INCLUDING RELEVANT LABORATORY RESULTS)
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
……………………………………………………………………………………………………………………………………………………………………………...…
…………………………………………………………………………………………………………………………………………………………………………..........
DESCRIBE HOW THE REACTION WAS TREATED:
............................................................................................................................. ...................................................................................................................
............................................................................................................................. ...................................................................................................................
............................................................................................................................. ...................................................................................................................
............................................................................................................................. ...................................................................................................................
Outcome of reaction:
Recovered completely Not yet recovered Recovered with long term consequences
DATE OF RECOVERY (Day/Month/Year): ........ / .......... /..........
MEDICINES (List the medicines suspected of causing the reaction as well as all concomitant medicines)
Brand name & Batch No.
(List suspected drug first)
Daily dosage Route Date started Date stopped Reasons for use
26
........ / .......... /.......... ........ / .......... /..........
........ / .......... /.......... ........ / .......... /..........
COMMENTS: (e.g. include relevant medical history, drug allergies, previous exposure to similar drugs, other lab data)
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
............................................................................................................................. ...................................................................................................................
................................................................................................................................................................................................................................................
Reporting doctor, pharmacist or health care professional
NAME: ........................................................................................................... QUALIFICATIONS.........................................................................................
ADDRESS: ............................................................................................................................... .................................................................................................................
.............................................................................................................................................. ..................................................................................................
............................................................................................................................................................. ...................................................................................
SIGNATURE: ............................................................................................... TEL:........................................................................................................................
DATE OF thi s re PORT (Day/Month/Year): ........ / .......... /..........
Advice about voluntary reporting
Please report: suspected adverse drug reactions and interactions with all drugs;
...............................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................
Serious adverse medicine reactions include all cases resulting in:
death;
life-threatening events;
permanent disability or incapacity;
congenital anomalies;
. hospitalization or prolongation of hospitalization as a result of the event;
other events, which you may deem to be serious or important:
................................................................................................................................................................................................................................ ...............
.................................................................................................................................................................................................................................................
Report even if:
you are not certain the product caused the reaction;
you do not have all the details.
Important numbers and
address:..............................................................................................................................................................................................................................................................
27 ............................................................................................................................. ...........................................................................................................................................................
........................................................................................................................................................................................................................................................................................
Who to report to: Please send this report to the Pharmacovigilance coordinator at your nearest district hospital
........................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................
Confidentiality: Identities of the reporter and patient will remain strictly confidential.
Your support of the adverse drug reaction monitoring Programme is much appreciated.
Information supplied by you will contribute to the improvement of drug safety and therapy in our count
Note: - check list attached -2 pages.
Checklist for investigation of suspect adverse drug reaction
1. Confirm information in report:
• obtain patient’s medical file (or other clinical record);
• check details about the patient and the event from the medical file and document the information;
• obtain any details missing from the suspect adverse drug reaction report form;
• identify any other cases that should be included in the investigation.
2. Investigate and collect data about the patient:
• history of drug use (including the use of over-the-counter and traditional medicines);
• medical history, including prior history of similar reactions or allergies;
• family history of similar events.
3. Investigate and collect data about the event:
• history, clinical description, any relevant laboratory results and diagnosis of the event;
28
• treatment, whether hospitalized and outcome.
4. Investigate and collect data about the suspected drug(s):
• conditions of storage at facility and expiry date.
5. Investigate and collect data about other people:
• whether others received the same drug and became ill (assess health facility ledgers);
• whether others had similar symptoms (may need case definition); if so, exposure to suspect
drug(s);
• conditions at the local health facility.
6. Assess the service by asking about:
• drug storage and prescription;
• details of training in diagnosis and treatment;
• whether the number of treatments was higher than normal.
7. Formulate a working hypothesis about the probable cause(s) of the event
8. Test the hypothesis:
• does the case distribution match the working hypothesis?
• occasionally, laboratory tests may help.
9. Conclude the investigation:
• assess the causal association with the suspected drug(s);
• take corrective action, and recommend further action (see section 11).
10. Assess outcome of actions or lack of action taken and assess the impact of any
corrective action taken (where appropriate).
29
MONTHLY REPORT RETURN FORMAT
MALARIA AMONGST TROOPS & FAMILIES FOR THE M/O ___________20 ___
Nam
e of
Un
it /
HQ
TROOPS FAMILIES Grand
Total
Fre
sh
Rel
apse
To
tal
Fre
sh
Rel
apse
To
tal
PV PF PV PF PV PF PV PF PV PF PV PF PV PF
MALARIA & OTHER VECTOR BORNE DISEASES FOR THE M/O____________________20___
NA
ME
OF
HQ
/UN
IT
TO
TA
L C
AS
ES
TE
ST
ED
BY
RD
T/M
ICR
OS
CO
PY
TO
TA
L M
AL
AR
IA C
AS
ES
PV
+P
F
MA
LA
RIA
PF
CA
SE
S
PV
CA
SE
S T
RE
AT
ED
WIT
H C
Q+
PQ
PF
CA
SE
S T
RE
AT
ED
WIT
H A
CT
+P
Q
SE
VE
RE
CA
SE
ON
MA
LA
RIA
(IN
DO
OR
CA
SE
S T
RE
AT
ED
WIT
H
AR
TIS
UN
AT
E/Q
UIN
INE
DE
AT
H D
UE
TO
MA
LA
RIA
PF
/PV
SE
PA
RA
TA
LY
DE
NG
UE
(E
LIS
A C
ON
FIR
ME
D A
S
PE
R G
UID
EL
INE
S)
KA
LA
ZA
R
CH
IKE
NG
UN
IYA
SU
SP
EC
TE
D
HIK
EN
GU
NIY
A C
ON
FIR
ME
D
AC
UT
E E
NC
EP
HA
LIT
IS S
YN
DR
OM
E
(AS
PE
R G
UID
EL
INE
)
JAP
AN
ES
E E
NC
EP
HA
LIT
IS
(CO
NF
IRM
ED
BY
MC
EL
ISA
)
FIL
AR
IA C
AS
ES
LY
MP
HO
ED
EM
A /
HY
DR
OC
OE
L S
EP
AR
AT
AL
Y
RD
KIT
MICRO
SCOPY PV PF
Signed by
[Dr C B Narayan), CMO(SG)]
I/C, Malaria Cell, BSF
Comp Hospital, BSF Agartala
