CONTROL OF MALARIA

APPROACHES TO MALARIA CONTROL1. Management of malaria cases in the

community.2. Active intervention to

control/interrupt malaria transmission with community participation.

MANAGEMENT OF MALARIA CASES IN THE COMMUNITY Should be given first priority. Healthy guides and multipurpose workers

are fully trained to detect and treat malaria cases at community level with support from referral system.

Govt have also established drug distribution centres and fever depot all over the country.

NATIONAL DRUG POLICY ON MALARIA,2010

National Drug Policy on Malaria was first formulated in 1982 and has subsequently been reviewed and revised periodically.

Emphasis on complete treatment in

diagnosed cases of malaria rather then

one single dose presumptive treatment to

suspect the case of malaria to avoid

choloroquine resistance in P.falciparum.

The first line of treatment is choloroquine

AIMS Providing complete cure (clinical and

parasitological) of malaria cases Prevention of progression of uncomplicated

malaria into severe malaria and thereby reduce malaria mortality.

Prevention of relapses by administration of radical treatment

Interruption of transmission of malaria by use of gametocytocidal drugs

Preventing development of drug resistance by rational treatment of malaria cases.

TREATMENT OF UNCOMPLICATED MALARIA

GENERAL RECOMMENDATIONS FOR THE MANAGEMENT OF UN COMPLICATED MALARIA

Avoid starting Rx on empty stomach., 1st dose given under observation., Dose repeated if vomiting within 30

minutes Patient should report back if no

improvement after 48 hrs. Patient should be examined for concomitant

illness.

All fever cases suspected to be malaria should be investigated by microscopy or RDT

TREATMENT OF MIXED INFECTIONS (P.VIVAX + P.FALCIPARUM) CASES All mixed infections should be treated

with full course of ACT and Primaquine 0.25 mg per kg body weight daily for 14 days

TREATMENT OF PLASMODIUM VIVAX

P.vivax cases should be treated with chloroquine for three days and Primaquine for 14 days

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.

2. Primaquine: 0.25 mg/kg body weight daily for 14 days.

Primaquine is used to prevent relapse. Contraindicated in pregnant women,

infants and individuals with G6PD deficiency

Patients should be instructed to report back in case of haematuria or high colored urine /cyanosis or blue coloration of lips and Primaquine should be stopped in such cases.

Care should be taken in patients with anaemia

TREATMENT OF PLASMODIUM FALCIPARUM Chloroquine first drug of choice If chloroquine resistant, then Artesunate combined

therapy(ACT) ACT consists of Artesunate combined with a long

acting antimalarial like sulfadoxine and pyrimethamine

Artesunate 4 mg/kg body weight daily for 3 days Sulfadoxine (25 mg/kg body weight) –

Pyrimethamine (1.25 mg/kg body weight) on first day

Primaquine 0.75 mg/Kg body weight on Day 2

Patient resistant to ACT-quinine is drug of choice.

SEVERE MALARIA

CLINICAL FEATURES :- a)impaired conciousness/coma b)repeated generalized convulsions c)renal failure(serum creatinine >3mg/dl) d)jaundice(serum bilirubin >3mg/dl) e)severe anaemia(Hb <5mg/dl) f)pulmonary edema/ARDS g)hypoglycaemia(plasma glucose<40mg/dl) h)metabolic acidosis i)circulatory shock(systolic BP<80mmHg) j)abnormal bleeding and DIC k)haemoglobinuria,hyperthermia

(temp>104degree F)&hyperparasitaemia

SEVERE AND COMPLICATED MALARIA

Choice of antimalarial is quinine injection 10mg/kg body wt. I.V drip in 5% dextrose saline to be runover

4hrsTotal duration of treatment is of 7 days

Injectable form of artemisinine derivatives may be used for the management of the sever complicated malaria in adult and non-pregnant women only

Artesunate 2.4mg/kg bw IM or IV followed by 1.2mg/kg bw once daily for

4 daysTotal duration is 5 days

Artemether1.6mg/kg bw IM followed by 1.6mg/kg bw daily for total 6

injection or twice for 3 days Artether

150mg daily IM for 3 days Only for adult

Artemisinine10mg/kg bw at 0 and 4 hours followed by

7mg/kg bw at 24,36,48 and 60 hours

TOXIC HAZARDS OF DRUGS

Choloroquine has few side effects like nausea,

vomiting, blurring of vision and headache.

Cases of retinal damage has been reported but only

in a person exposed to large cumulative dose over

many years

Choloroquine should not given to empty stomach.

Symptoms may be of three typesPlasmocid types

Rare toxic manifestation involving the CNS Gastrointestinal

Cramps,nausea and vomitingCardiovascular

Most serious toxic menifestation

MASS DRUG ADMINISTRATION

It is recommended for highly infected endemic areas

It is not recommended to children under 5 : Impossible to achieve continuous suppression

in a significant proportion of the population Interfere in the development of promotive

immunityMay accelerate devlopment of drugs resistanceMay increase the risk of retinopathy

CHEMOPROPHYLAXIS Chemoprophylaxis should be administered only in

selective groups in high P.falciparum endemic areas. This is recommended for travelers to endemic

areas,soldiers,police and labour forces working in endemic areas

Recommendations for dosing are:-

1)dose for children should be based on body weight

2)daily anti malarials should started the day before travel(eg:-doxycycline)

3)weekly chloroquine started 1 week before arrival

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.

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

ACTIVE INTERVENTION MEASURES1. Stratification of problemEssential feature for planning and development of a sound control strategy to maximise utilization of available resources.Provide guidelines as to which strategy could be most suited.

Action For individual and family protection

For community protection

Reduction of human- mosquito contact

Insecticide-treated nets,repellants,protective clothing,screening of houses.

Insecticide-treated netsZooprophylaxis

Destruction of adult mosquitoes

Insecticide-treated nets,indoor residual spraying,space spraying

Destruction of mosquitoe larvae

Peri-domestic sanitation

Larviciding of water surfaces,intermittent irrigation,sluicing

Source reduction Small scale drainage Environmental sanitation,water management,drainage

Social participation Motivation for personal and family protection

Health education,community participation

2. Vector control strategyAnti-adult measures

Residual spraySpraying indoor surface of house with

DDT/malathion.Discontinuation lead to resurgence of malaria.Reduces the longevity of vector.

Space applicationMajor anti-epidemic measure Involves application of pestisidesin the form of

fug or mist using special equipments

Individual protection Man-vector contact can be reduced by

Using nets, protecting cloth, coils, repellents,screening of houses.

Anti-larval measureLarvicides

Oiling the collection of standing water or dusting them with paris green effectively controlled malaria.

Some moderm larvicides such as temephos which confer long effect with low toxicity are more widely used

Source reduction Techniques to reduce mosquito breeding sites

drainage or filling. Deepening or flushing Management of water level Changing the salt content of water Intermittent irrigation

Integrated control In order to reduce too much dependence

residual insecticides, increasing emphasis is being put on integrated vector control methodology which includes bio-environmental and personal protection measure

GLOBAL POLICY FOR DIAGNOSIS AND TREATMENT OF MALARIA

The Govt of every country affected by malaria has a National control policy covering prevention and case management

Objectives are Ensure rapid cure of infection Reduce morbidity and mortality, including malarial

related anemia Prevent the progression of uncomplicated malaria

into severe disease Reduce the impact of malarial infection on the fetus

during pregnancy Reduce the reservoir infection Prevent the emergence and spreading of drug

resistance and prevent malaria in travellers

ROLL BACK MALARIA Malaria control added impetus as initiative

was launched by WHO,UNICEF,UNDP and world bank in 1998 .

Aim:-to reduce the Deaths and incidence To 75% by 2015.

MALARIA VACCINE Vaccination against malaria is a burning

issue today Several vaccine candidates are now being

tested in africa, asia and US A vaccine developed in columbia (SPF 66)

advanced to phase 3 trials in africa but failed to show efficacy in chiildren under 1

Another vaccine (RTS, S/AS02) with the potential to prevent infection and ameliorate disease is being tested by GlaxoSmithKline and the MVI at PATH in Phase I trial in Gambia

In phase II in 2002 trials of the vaccine are being conducted among the children in Mozambique, which suffers from year-round malaria transmission offering a better opportunity to evaluate vaccine performance

This vaccine has been safely tested in adult volunteeers in Belgium, Gambia, kenya and US

only potential malarial vaccine

THANK YOU…