1) The document provides guidelines for the diagnosis and treatment of malaria in India, outlining recommendations for diagnosing and treating both uncomplicated and severe malaria. 2) Diagnosis is primarily done through microscopy of blood smears, with rapid diagnostic tests and other tests also used. Uncomplicated malaria is generally treated with chloroquine or artemisinin combination therapy depending on the malaria species. 3) Severe malaria requires hospitalization and management of complications along with parenteral antimalarials such as artesunate or quinine. Drug resistance is an ongoing challenge requiring close monitoring.

1. DIAGNOSIS AND
TREATMENT OF MALARIA
DR.KRITHIGA S.
Based on Guidelines for Diagnosis and Treatment of Malaria in India 2011 - GOI
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2. FRAME WORK
• Introduction
• Diagnosis
• Aims of treatment guidelines
• Treatment of uncomplicated malaria
• Drug resistance
• Complications and management of severe malaria
• Treatment for complicated malaria
• Chemoprophylaxis
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3. Introduction
• MALARIA - major public health problem – 1.5 million
confirmed cases (India ,2010)
• WHO recommends all malaria endemic countries should
evolve their own national anti- malaria drug policy
• It is a set of recommendations and regulations regarding the
availability and rational use of antimalarial drugs in a country.
• It should be the part of the national essential drug policy & the
national malaria control policy (overall national health policy).
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4. Indroduction
• India’s first national anti - malaria drug policy was drafted in 1982.
This reviewed periodically based on sensitivity studies and current
National Drug Policy on Malaria has been revised in 2011 & adopted
by MOHFW.
• The main purpose  provide a framework for the safe and effective
treatment of uncomplicated & severe malaria as well as prevention of
malaria in travellers and vulnerable groups.
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5. Diagnosis
• Microscopy
• Rapid diagnostic test
• Other tests
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6. Microscopy :
• Peripheral blood smears – Gold standard
• Thick and thin smears
Advantages
• Sensitivity is high
• Detects parasites even at low densities
• Quantify the load
• Distinguish between various species and different stages
• Requires skills to identify.
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7. Rapid Diagnostic Test
• Dipstick test
• Immunochromatographic test for detection of malarial
antigens(monoclonal /polyclonal antibodies)
• Detetction of antigens -HRP2, Aldolase, pf LDH
•Faster, Needs only little training
• Has good sensitivity
•Expensive and temperature sensitive
•The antigen may persist upto 2 weeks
after parasite clearance
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8. Other tests
• QBC
• Serological test
• Parasight F,Optimal assay
• PCR
• Sternal or liver puncture
• Radioimmuno assays, Immuno fluorescence
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9. Effective treatment policy
All malaria control activities in India come under National vector borne
disease control programme
Aims :
• Complete cure
• Interruption of transmission
• Reduce the progression of uncomplicated malaria to severe disease &
prevent mortality
• Minimizing risk of spread of drug resistant parasites
• Prevention of relapse
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10. TREATMENT OF UNCOMPLICATED
MALARIA
General recommendations
• Avoid starting treatment on an empty stomach. The first dose - under observation.
• Dose repeated if vomiting < 30 minutes.
• Report back, if there is no improvement after 48 hours or if the situation deteriorates.
Treatment of P. vivax malaria
• Confirmed Cases - Chloroquine in full therapeutic dose of 25 mg/kg divided over
three days.
• To prevent relapse (Hypnozoites )-Primaquine 0.25 mg/kg bw daily for 14 days
under supervision
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11. Treatment of P. falciparum malaria
• Artemisinin Combination Therapy (ACT) should be given to all
confirmed P. falciparum cases found positive by microscopy or RDT.
• ACT --an artemisinin derivative + with a long acting antimalarial
(amodiaquine, lumefantrine, mefloquine or sulfadoxine-pyrimethamine).
• On day 2 ,single dose primaquine (0.75 mg/kg body weight).
• The ACT recommended in the National Programme of India is artesunate (4
mg/kg body weight) daily for 3days and sulfadoxine (25 mg/kg body
weight) -pyrimethamine (1.25mg/kg body weight) on Day 0.
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12. • Presently, fixed dose combinations of artemether + lumefantrine, artesunate +
amodiaquine and blisterpack of artesunate + mefloquine are registered for
marketing in India and are available for use.
These rapidly acting drugs, if used alone, can lead to development of drug resistance.
Treatment of Malaria in pregnancy
• ACT : second and third trimesters
• Quinine : in the first trimester
• P. vivax malaria can be treated with chloroquine
Oral artemisinin monotherapy is banned
in India
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13. Treatment of mixed infections
• Mixed infections should be treated as falciparum malaria.
• However, antirelapse treatment with primaquine can be given for 14
days, if indicated.
• Clinical malaria (clinical criteria without laboratory confirmation) is
treated with chloroquine in full therapeutic dose of 25 mg/kg body
weight over three days.
If a slide result is obtained later, the treatment should be completed according
to species.
•Suspected cases of malaria ,negative on diagnostic tests should be treated with
full therapeutic dose of choloroquine22-12-2014 13

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15. 22-12-2014 15
DRUG SCHEDULE UNDER NVDCP

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17. 22-12-2014 17

18. Drug Resistance: Malaria
Major public health problem ,hinders the control of malaria
• In India resistance of falciparum to chloroquine, the first reported in the year 1973
(Diphu of Karbi-Anglong district in Assam state. )
• NVDCP monitors the response of antimalarial drug in Pf malaria parasite in the
through 13 monitoring teams located in 11 Regional Office for Health & Family
Welfares
Objectives:
• To assess the therapeutic response of P.falciparum to currently used anti-malarials
• To establish and generate information on sensitivity of local strains for formulation
of National Drug Policy and recommend needful changes in the control
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19. Tools for monitoring
• From 2002-03 onward, new WHO protocol on "Therapeutic efficacy of anti-malarial
drugs in uncomplicated P.falciparum malaria" is being followed to assess the
efficacy of antimalarial drugs.
• The classification of response according to new protocol is interpreted into three
categories as per the WHO criteria i.e Adequate Clinical and Parasitological
Response (ACPR), Early and Late Treatment Failure (LTF).
• Adequate response : if no fever or parasitaemia till Day 28.
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20. Early treatment failure (ETF):
Development of danger signs or
• severe malaria on Day 1, 2 or 3, in the presence of parasitaemia;
• PARASETIMIA on Day 2 > on Day 0, irrespective of axillary temperature;
• Day 3 with axillary temperature>37.5°C;
• Day 3, >25% of count on Day 0.
Late clinical failure (LCF):
Development of danger signs or
• Severe malaria in the presence of parasitaemia on any day between Day 4 and
Day 28 (Day 42)
• Presence of parasitaemia on any day between Day 4 and Day 28 (Day 42) with
axillary temperature >37.5°C
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21. Late parasitological failure (LPF):
• Presence of parasitaemia on any day between Day 7 and Day 28 with axillary
temperature <37.5°C in patients who did not previously meet any of the criteria of
early treatment failure or late clinical failure.
Alternative treatment -Alternative ACT or quinine with Doxycycline.
• To combat the drug resistant in malaria, the National Drug Policy on Malaria
recommends the use of combination therapy in chloroquine resistant areas,
surrounding cluster of Blocks and 117 high endemic districts
• Criteria for change of drug policy
Drug policy is changed for the area/Block PHC reporting 10% or more total
treatment failure (ETF+LTF) to the currently used antimalarials in a sample of
minimum 30 P.falciparum test cases.22-12-2014 21

22. SEVERE MALARIA
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23. Severe manifestations
General
•Jaundice (Serum Bilirubin >3 mg/dl)
•Hyperpyrexia (Temperature >106 F or >42 C)
• Hyperparasitaemia (>5% parasitized RBCs)
CNS
•Impaired consciousness/coma
•Repeated generalized convulsions
Metabolic :
•Hypoglycaemia (Plasma Glucose <40 mg/dl)
• Metabolic acidosis
Circulatory
•Severe anaemia (Hb <5 g/dl)
•Pulmonary oedema/acute respiratory distress syndrome
• Circulatory collapse/shock (Systolic BP <80 mm Hg)
•Abnormal bleeding and DIC
Renal :
Renal failure (Serum Creatinine >3 mg/dl), Haemoglobinuria22-12-2014 23

24. Management of Complicated malaria
Requirements for management of complications
Health facilities should be equipped :
• Parenteral antimalarials, antipyretics,
antibiotics,anticonvulsants
• Intravenous infusion facilities
• Special nursing for patients in coma
• Blood transfusion
• Well-equipped laboratory
• Oxygen
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25. Management of other signs and complications
Hyper pyrexia (rectal temp >39 c) •Tepid sponging
•Cool environment
•Para 5mg/kg/bw
Dehydration •IV fluids
•Monitor I/O
Acute renal failure(with
anuria/oliguria/blackwaterfever)
•IV fluids
•Furosemide IV or IM
•Dialysis
•Watch on urea/creatinine/k levels
•Alkanize the urine
Hyperkalemia •>7mmol
•Ca charged resins 15-30gms TDS
•If >60mol NaHco3 infusion with insulin
Hypokalemia •10 cc KCl in 24 hrs22-12-2014 25

26. Pulmonary edema •Prop up 45 ,oxygen
•Fluid balance and diuretics
GIT symptoms •IV fluids, chlorpromazine IV or IM
Shock •IV plasma expanders
•Corticosteriods
•Dopamine
Anemia(PCV <20, HB <7), bleeding •Whole blood /Packed cell transfusion
•Vit K (bleeding)
Convulsions •Diazepam (0.2 mg/kg/Bw)IM or IV 8hrly
•Phenytoin sodium 5 mg/kg/bw
•Phenobarbitone 5-10 mg/kg/Bw
Hypoglycemia •IV glucose 50% followed by 5-10% glucose
•Monitor blood sugar levels
Hyperparasaitemia •Exchange transfusion
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27. Severe malaria :
cases negative on microscopy
– asexual parasites in patients with severe infections
– due to sequestration and partial treatment.
• Confirm by RDT or repeat microscopy
• If clinical presentation indicates severe malaria and there is
no alternative explanation these patients, treated accordingly.
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28. Specific antimalarial treatment of severe malaria
• Parenteral artemisinin derivatives or quinine should be used irrespective of
chloroquine sensitivity.
DRUG DOSE
• Artesunate: 2.4 mg/kg body weight i.v. or i.m. given on admission (time=0),
then at 12 hours and 24 hours, then once a day (Care should be
taken to dilute artesunate powder in 5% Sodium bi-carbonate
provided in the pack).
Artemether: 3.2 mg/kg body weight i.m. given on admission then 1.6 mg/kg
body weight per day
• Arteether:
150 mg daily i.m. for 3 days in adults only(not recommended
for children)
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29. Quinine:
20 mg quinine salt/kg body weight on admission
• (i.v. infusion in 5% dextrose/dextrose saline over a period of 4 hrs)
followed by maintenance dose of 10 mg/kg bodyweight 8 hrly;
• infusion rate should not exceed 5mg/kg body weight per hr
• Loading dose of 20 mg/kg body weight should not be given, if the
patient has already received quinine.
• NEVER GIVE BOLUS INJECTION OF QUININE.
• If parenteral quinine therapy needs to be continued beyond 48 hours,
dose should be reduced to 7 mg/kg body weight 8 hourly
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30. Once the patient can take oral therapy, further follow-up treatment should be as
below:
• Patients on parenteral quinine should be treated
• oral quinine 10 mg/kg body weight TDS to complete a course of 7 days,
• Along with doxycycline 3 mg/ kg body weight per day for 7 days. (If
contraindicated, Clindamycin 12 hourly for 7 days should be used).
• Patients receiving artemisinin derivatives should get full course of oral
ACT. However, ACT containing mefloquine should be avoided in cerebral
malaria due to neuropsychiatric complications.
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31. • IV prefered over IM , should be given for min of 24 hours once
started.
•
Severe malaria due to P. Vivax
• Rare in India
• Treated like severe P. falciparum malaria
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First trimester Parenteral quinine (DOC)
Artemisinin derivatives
In Second and Third trimester Parenteral Artemisinin

32. • Chemoprophylaxis
Recommended for travellers, migrant
labourers and military personnels
• Use of personal protection measures
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33. Chemoprophylaxis
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Less than 6 weeks
• Doxycycline: 100 mg daily in
adults and 1.5 mg/kg body
weight for children > 8 years
• started 2 days before travel
and continued for 4 weeks
after leaving the malarious
area
Greater than 6 weeks
• Melfoquine 250mg weekly
2 weeks before,during and 4
weeks after exposure
• It is contraindicated in people
with h/o convulsions,neuropsy
problems and cardiac
conditions.