Upgraded 2020 Malaria Management booklet in English by Dr Narayan

3
FOREWORD
Dr CB Narayan,CMO(SG)isa well-disciplined, highly professionaland dedicated doctor
of BSF. Presently, he is looking after various staff duties in Composite Hospital Agartala, As
Incharge of BSF Malaria Cell since 2017, he has notably improved the Health Care System in
better interest of paramilitary personnel and their families.
The idea of undertaking study on the reason of recent surge in PF Malaria Index was
conceived & directed by then Director Medical of BSF, which was further advocated by
Additional Director General (Medical), CAPFs
.
This endeavor to pen down the SOP on Malaria with updated modality of prevention &
treatment will certainly be a source of illumination for the doctors & forces deployed in far
flung Border & Naxal areas of the country.

5
PREFACE
During my entire 22 years of service, I never confronted such pity situation
before my assignment as Incharge of Malaria Cell regarding the treatment of Malaria
during my prolonged tenure of more than 7 years in various Malaria pockets on the
globe including forest of North -East states, Naxal affected jungles of India and PF
infested Democratic Republic of Congo.
It was hot noon as usual in Agartala, I was busy in my various files in OPD,
sudden I got a call from Emergency to see a patient who reported from border, the patient
was not able to come down from Ambulance, so I rushed inside ambulance. His clinical
parameters were sinking as he was having C/O pain abdomen, headache and severely
dehydrated. His eyes were moderately icteric, Serum Bilirubin reported around 9 mg/dl,
BP was 90/60 mm Hg only. Reportedly his urine output was low. As his MP reports on RD
Kit were repeatedly Negative, ACT/Antimalarials were not started despite H/O fever for 5-
6 days. The patient was conscious but panicked about his illness. I immediately decided to
transfer this case to only corporate hospital in Agartala which was having ICU facility. In
the evening I was reported that the case was put on ventilator as he was detected having
Multi Organ Failure, and next day only I heard about his fatal outcome of brain death. I
was shaken from core of heart while saluting this patient turned dead body whose words
were still ringing in my ears “JALDI KARO SAHAB, PET ME DARD HO RAHA HAI.”
It was seeming a PF Negative Clinical Malaria case where most of the doctors get cheated
& loose the patients. Then I decided to do something for the coming generations of doctors
in BSF so that these types of deaths could be avoided & precious lives of PF Negative
Clinical Malaria cases is not lost in ignorance & we remain mute spectator only.
While compiling the data of Malaria, I noticed a definite troubling shift in the
downward trajectory of PF Malaria incidence in BSF after 2017. I got an opportunity
to present my case on Malaria Menace in a CME in CH BSF, Agartala. Then only few
doctors of Tripura Frontier came to know that really it could be a problem not only
for BSF but for the whole nation in future. Ultimately on being entrusted to carry out
a study to find reason behind surge in Malaria Index and finally a directive to write
SOP on Malaria incorporating my study outcome, I started refueling the Malaria
Lamp, which was twinkling in my laptop. I gone through available books on Malaria,
discussed the matter with doctors in State Malaria Health Authorities of Tripura &
finally on the platform of my exposure to various complicated Malaria Cases I tried to
spark the candle, this Malaria Lamp is in your hand now.

6
STUDY/ANALYSIS REPORT ON THE REASONS FOR RECENT SURGE IN
MALARIA CASES IN TROOPS OF TRIPURA FRONTIER
The board comprising (1) Dr CB Narayan, CMO(SG), CAPF’s Hospital
Agartala & (2) (Dr Subrata Debnath), GDMO(Cont.) having assembled pursuant to HQ
DG BSF Med Dte Signal No A/1742 Dated 19 Aug ‘2019 & Comdt Medical Ftr HQ
Tripura Let No -IGA/Med/Visit-Inspection/19/1241-42 Dated 20 Aug ‘2019, proceeded
to visit various BOPs of 66 Bn (Bagafa), 164 Bn (Maharanichera), 133 & 158 Bn
(Nalkata) & 86 Bn Ambassa & inquired with the State Health Authorities of Tripura in
Agartala, from where most of the cases reported in recent months.
The board interpreted the data of Malaria Cell of BSF vis a vis Malaria Statistics
of civil population of Tripura, Rain Fall statistics of Tripura & further interacted with the
company commanders, troops as well as civil population in border area and came to the
under mentioned observations & on the direction from HQ DG BSF (Medical Directorate)
vide their Sig No - A/1743 Dated - 18/10/2019, derived updated SOP on Malaria
Management for BSF.

7
CONTENTS
S/No Topic Page No
1. Preface 5-6
2. Study Report 9-13
3. Peculiarity about Mosquito Bite 14-15
4. Clinical Parameter 15-17
5. Treatment 18-20
6. Preventive Measures 21-25
7. Do’s & Don’ts Pamphlet on Malaria 26
8. Malaria Card 27
9. DDT Spray (Appendix-A) 28
10. Impregnation of Nets (Appendix-B) 29
11. Signages Poster (Appendix-C) 30
12. Danger Sign / Criteria for Referral (Appendix-D) 31
13. Treatment & Referral Protocol (Appendix-E) 32
14. CAB Management (Appendix-F) 33
15. CPR Poster 34
16. Investigation Report on Death Format (Appendix-G) 36
17. Suspected Adverse Drug Reaction Report Format
(Appendix-H)
40
18. 44 45

9
In contrary to down fall, PF index is surging in BSF
Gross Surge in IPD cases in CH Agartala in 2018 & 2019 in comparison to 2017
0
100
200
300
400
500
600
700
800
900
2014 2015 2016 2017 2018 2019
BSF PF cases Surging after 2017
PF Cases PV Cases 2 per. Mov. Avg. (PF Cases) 2 per. Mov. Avg. (PV Cases)
512.4
325.25
105.46 70.49 130.79 74.32
810
537
216
132 157 270
2014 2015 2016 2017 2018 2019
Parallel Surge in PF Cases in Civil & BSF in Tripura
PF in Civil in Hundred PF in BSF
1 1 11 4
20
6
7
30
0
5
4
0
10
20
30
40
50
60
2017 2018 2019
IPD PF-Cases in CH Agartala
1st QTR 2nd QTR 3rd QTR 4 th QTR

10
If we see area chart of 3 year Prospective % contribution of PF Cases in Tripura Frontier
Vs BSF index. In 2017 Tripura contributed 31% out of 58% which is more than half
(53%), in 2018 it increased to 37% out of 27% ie (137%), & in 2019 it went up to 32%
Vs 15% ie (213%). Error in data may be due to Except Tripura, other frontier not sending
data accurately & on time.
In civilians of Tripura state, Malaria Index seems surging after 2017
0
100
200
300
400
500
600
2014 2015 2016 2017 2108 2019
PF in hundred Death
2 per. Mov. Avg. (PF in hundred) 2 per. Mov. Avg. (PF in hundred)
2 per. Mov. Avg. (Death)
% CONTRIBUTION OF TRA-FTR Vs BSF

11
1. Prevalence
of Sub-
Clinical
Carriers &
PF loaded
Mosquitoes
in Eastern
Border
pockets of
Tripura
Since most of the civil population in border area
are subclinical carriers of certain species of PF. Right
from childhood they sleep mostly in open & sustain
repeated mosquito bites resulting in development of
Splenomegaly & Immunity against that pocket specific
strain of plasmodium as few of them found Positive
during random check on RD Kits.
In recent years, RD Kits are made available in
abundance for civil population by state Govt and as the
subclinical cases are being tested in abundance, they are
recorded as positive and reported there after which
enhances the data.
Troops should be
instructed not to expose them
uncovered during local marketing
& public interactions and strictly
adhere to the SOP against Malaria
as recently updated on the website
of Composite Hospital Tripura in
(www.tcm.bsf.gov.in)
For Treatment of PF
Negative cases highest level of care
needs to be taken assuming them
as Clinical Malaria Case (if
patient remain symptomatic after
3 days)
2. Non-irritant
& Silent
nature of
Mosquito
bite in
Tripura
Border
pockets
In boarder area, there are plenty of herbs & vegetation,
most of the mosquitoes there thrive on nectar & plant
juices, the bite of those mosquitoes is mostly silent, non-
irritant in nature in contrast to that of inner cities &
town of India where mosquitoes remain in dirty stinking
drains. Troops fell prey of these silent, non-irritant bite
& remain in dilemma that they haven’t been bitten by
mosquito even while sleeping open without mosquito-
net.
Troops should be instructed not to
expose them uncovered during
local marketing & public
interactions and strictly adhere to
the SOP against Malaria as
uploaded on the website of
Composite Hospital Tripura in
(www.tcm.bsf.gov.in)
3. Scarcity of
Water in
summer
months
Troops don’t have sufficient water to take daily evening
bath after duty in hot humid climate especially in the
M/O April-May. In 2019 Rain Fall remain below
average as evidenced here.
Scope of Deep Bore Tube Well
should be explored in more places
in Border area so that troops can
be able to maintain personal
cleanliness & Hygiene up to mark.
4.
BELOWAVERAGERAINFALLIN
NE&TRIPURA

12
5. Deep Bore Tube
Well facility at
Dyke-VIII BOP at
Maharanichera of
164 Bn supplying
clean potable
water to 3 nearby
BOPs
6. From
Nearby
Water
reservoir it
is being
lifted to
Company
HQ
7. There are various modes of
water being used in border
area as mentioned in para 5-
7, more sources needs to be
explored for remaining BOPs
like
i) Deep Bore as Para-5
ii) Pond nearby as Para-6
iii) Water Harvesting as
Para-7
-
8. RD Kits
Sensitivit
y &
Specificit
y
➢ Now a days NVBDCP using Combd
RD Kits which contains HRP-II (Pf)
& pLDH (PV) Antigens. It’s HRP-
II Antigen sensitivity last longer
than pLDH Antigen for PF cases,
which can show False-Positive for 3
months.
➢ Therefore, there is chances of
overcounting of PF cases if we go
only on RD Kit result.
➢ Also, there may be confusion in
distinguishing fresh infection and
➢The board checked more than 50
civilians including males, females
& children in AOR of Nalkata in
Tripura near BOP Pratap &
Jamanipara where only one case
was detected PF Positive who was
having C/O mild fever, means
mostly they are not carriers or PF
defies to be detected on kit.
➢NVBDCP recommended
Combined RD Kit should be
continued for fresh cases but for
Jamanipada, 133 Bn
BSF, Nalkata, Tripura
Simna-I, 133 Bn BSF,
Nalkata, Tripura
Dyke VIII, 164 Bn BSF,
Maharanichera, Tripura

13
False Positivity due to HRP-II
Antigen.
HRP2-detecting RD Kits are more
stable than pLDH as well as Aldolase
detecting RD Kit, therefore it is better
suited for outdoor set up.
repeaters pLDH bases Optimal
variant should be used.
The report of Malaria cases should
be sent properly mentioning
repeaters frequency to avoid over
reporting of cases.
9. Availabilit
y of
trained
Manpower
in
units/BOP
s
Trained doctors & NA are available in units in
hard areas but they need to be updated time to
time about hurdles in diagnosis & treatment of PF
Negative cases.
Bimonthly CME/Seminar
should be held at CH Agartala
on Malaria Management by
Malaria Cell, BSF.
10. 3 Basic
Needs –
I. Water
,
II. Electri
city,
Road
I. Water: - Inadequate Availability observed in
BOPs which might be contributing to the
Malaria Index surge.
II. Electricity: -No Electricity in most of the
hard area BOPs. Installed Solar Panels are
inadequate in number. Gen sets don’t have
sufficient POL. Troops use to sleep without
Mosquito Net sometimes as there is no
electricity for ceiling fan in hot humid
climate.
III. Roads: - were made along the fence during
2010-12 which are now badly damaged &
became nonpliable.
Bushes are encroaching over these roads.
Patient evacuation is delayed due to bad non
pliable road condition which further complicates
malaria cases.
I. Water: -
Recommendation as per
para 12-16 above
II. Electricity: -More Solar
panel may be installed &
also POL quota of Hard
area BOPs may be
enhanced.
Roads: - Repair work of roads
need to be expedited as most
of the administrative
enforcement depend on roads.

14
➢ Mostly bite at dusk and dawn or in the middle of the night.
➢ Mosquitoes are attracted by the body odors, carbon dioxide and heat emitted from
the animal or person. Our body emits different stinky smells (Octenol) from
different parts of our body. Sensors on antennae of mosquitoes locate our breath
odour easily & configure our exposed ankle & behind the Neck along hairline.
➢ Troops return to barrack heavily sweating, put their sweat laden
uniform on ropes which attract hungry waiting mosquitoes.
➢ Malaria Medicine produce heat / do harm if taken without being detected as PF
Positive on Slide/Kit, whereas Malaria drugs used in ACT are quite safe & there is no
any harm if taken by Clinical Malaria Patients as therapeutic dose who are found PF
Negative as per Dr CB Narayan’s 6 years of experience in treating CM patients.
➢ Why to start Anti-Malarial treatment in PF Negatives, whereas it is seen that 90 %
of complicated PF Malaria cases initially detected PF Negative & if malaria treatment
not started in time, these cases further get worsened with Multiorgan Failure.
➢ Don’t take bath in evening to avoid mosquito bite, whereas the biting schedule of
mosquitoes starts only after dusk in the evening when persons are sensed/identified by
the mosquitoes if they are sweat laden & stinky smelling. There fore ii) If water
available they may be allowed to take bath but in Net proof bath space.
➢ There are about 3500+ species of mosquito, of which about 100 are vectors of human
diseases.
➢ Mosquito has 2 stylets, one for sucking blood by capillary action & other for putting
saliva before puncturing which contains mild pain-killer and anti-coagulant action.
It can suck blood up to 3 times it’s own weight.
➢ 30-300 eggs/2-3 days
➢ Biting Range – Horizontal-Several Kms & Vertical up to 25 feet. But it is found even
on 8000 feet Himalaya and under 2000 feet Mines.
➢ Egg to adult – 1-2 week
➢ Adult life – Male mosquito live shorter span of 10 days where as Female can live up
to 5-6 months, average 2 months.
FEW PICULIARITIES ABOUT MOSQUITO & PLASMODIUM WORTH REMEMBERING
Theory behind How Mosquito identifies & Bites?
Some Misnomers about Mosquito-Bites?

15
➢ 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.
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.

16
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.
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

17
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)
➢ Decreased clearance by the liver.
➢ Most importantly the combined effects of several factors that reduce oxygen
delivery to tissues
➢ Marked reductions in the deformability of uninfected RBCs may
compromise blood flow through tissues
➢ Dehydration and hypovolemia can exacerbate microvascular obstruction by
reducing perfusion pressure
➢ Destruction of RBCs and anemia further compromises oxygen delivery.

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Role of Anti-Malarial Drugs in Treatment
Type of
Malaria
Drug Duration Purpose
PF 1) Inj Artisunate – 120 stat – 120 BD –
120 OD
2) Tab Lumither forte (ACT) -BD for 3
days in between Inj Artisunate
3) Tab Artisunate/Inj Arteether/Inj
Artemether
4) Tab PQ
7 days
3 days
7 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
3 days
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. The name
coined & posed by the author while he
was posted in Nalkata (Tripura) He used
to treat all these together.
1- Inj Ceftriaxone 3-5 days
2- Inj Metron
3- IV fluid in addition to
ACT-AL regime
Supportive
Medicines
1. Liver : - Syp Sorbillin, Tab Udilive, Tab Hepamerz
2. Antibiotic : - Inj Ceftriaxone, Tab Cefotaxim
3. Symptomatic : - PCM/Antiemetic/Multi-Vit

19
Treatment of Severe & Complicated PF Malaria
(Any one of these 4)
-------------------------------------------------------------------
i) Artisunate: 2.4 mg/kg IV or IM, at 0-12-24 hrs. then OD for 7 days,
switch over to ACT Oral in between when able to take oral
medication.
ii) Artemether: 3.2 mg/kg IM, at 0 hr. then 1.6 mg/kg OD for 7 days,
medication.
iii) Arteether: 3.2 mg/kg IM, at 0 hr. then 1.6 mg/kg OD for 4 days,
medication
iv) QDH: 20 mg/kg (Loading dose) diluted in 10 ml/kg D5 / DNS &
infused IV in 4 hrs., followed by 10 mg/kg (Maintenance dose)
infused IV in 4 hrs. in adult or 2 hrs. in children every 8 hrs. until
patient can swallow. Switch over to oral Quinine 10 mg/kg 8 hourly
to complete the 7-day course.
➢ In case of Volume Overload/Pulmonary Oedema, Volume of fluid for
IV infusion of QDH should be reduced.
➢ If available, oral Quinine should be substituted by 3-day oral ACT, or
Doxycycline 100 mg OD should be combined with it.
➢ Chloroquine HCL IV to be used only if none of the above is available
& only in adults.
Ref: - Medical Pharmacology by Dr KD Tripathi, 6th
edition, Page -
784* Adopted from Regional guidelines for the management of severe
falciparum malaria in large hospitals (2006); WHO, Regional office
for South-East Asia, New Delhi.

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STANDING INSTRUCTIONS ON PREVENTION, CONTAINMENT AND
MANAGEMENT OF MALARIA IN B.S.F. UNITS DEPLOYED IN
MALARIOUS HYPERENDEMIC ZONES
1. PROTECTION FROM MOSQUITO BITES WHILE ON DUTY OR OUTDOORS:-
➢ ALL TROOP PERSONNEL ARE TO WEAR THEIR SHIRT SLEEVES ROLLED DOWN.
➢ REPELLENTS: - 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). COMMONLY USED REPELLENTS ARE
ODOMAS, DIETHYL N TOLUAMIDE (DEET) (IT GIVES 6 TO 8 HRS
OF PROTECTION AGAINST MOSQUITOES.
➢ 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 TO 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’
➢ PUT SWEAT LADEN STINKY UNIFORM IN VARANDAH OUT SIDE BARRACKS WHILE
RESTING IN ROOMS/BARRACKS. THIS WILL DOODLE HUNGARY MOSQUITOS SEARCHING
YOU.
➢ 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’
➢ PUT SOME ODOMAS CREAM IN LOWER PORTION OF MOSQUITO NET WHILE SLEEPING
WHICH WILL WORK AS REPELLANT FOR FEW DAYS.
➢ 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.

22
(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:-
➢ ENVIRONMENTAL CONTROL- DRY DAY ONCE A WEEK IS TO BE STRICTLY FOLLOWED
FOR LEVELLING, FILLING UP OF DITCHES, DRAINING OF NATURAL PITS AND
EXFOLIATION OF BUSHES AND SHRUBS AROUND THE PERIMETER OF THE LOCATION OF
BOP’S.
➢ CHEMICAL CONTROL -PUT SOME LIQUID SOAP OR BURNT DIESEL, KEROSINE OIL TO
WATER BODIES ONCE A WEEK. SOAP WILL REDUCE SURFACE TENSION WHICH WILL
DROWN THE MOSQUITOS’ LARVAE WHO CAN NOT COME ON THE SURFACE TO BREATH.
SIMILARLY BURNT OIL WILL COVER THE SURFACE OF WATER WHERE MOSQUITOES CAN
NOT LAY EGGS.
➢ BIOLOGICAL CONTROL -LARVIVOROUS FISH LIKE GUPPY AND GAMBUSIA 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. MASS DRUG ADMINISTRATION (MDA) : -
MDA is the presumptive antimalarial treatment of an entire population to clear the subclinical
parasite reservoir is a potential strategy that can help accelerate malaria elimination.
➢ Dihydro-Artemisinin-Piperaquine and low-dose Primaquine for 3 months
➢ Mass drug administration (MDA) is an old strategy to delineate the residual malaria cases in most of
the endemic areas.

23
➢ With the help of Central & State Govt, this program can be executed in Border Area to flush out sub
clinical cases once & all.
7. MICROSCOPY AND PREVENTIVE SCREENING (MODIFIED QUARANTINE):-
Weekly Slide Check system should be in use during pick months ie from April to
October (3 months +/- of July)
SLIDE EXAMINATION FOR MALARIA PARASITE HAS BEEN DECENTRALISED AND
MINIMUM THREE BLOOD EXAMINATIONS WITH THE LAST EXAMINATION AT THE UNIT
HQr BE CARRIED OUT WHEN INDIVIDUAL 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 done 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.
8. 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.
9. 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.
10. 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 THERE 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.
RED ARTETHER BLUE ACT (ASP) ORANGE QUININE
YELLOW ARTEMETHER BLACK ACT(ALT) GREY VOMISTOP
GREEN ARTESUNATE WHITE PARACETAMOL RUST RANITIDIN

24
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.
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.
11. 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 DOES NOT COME DOWN WITHIN 24 HRS., EVACUATION BY
ANY AVAILABLE MEANS, SHOULD BE EFFECTED. (APPX-‘E’)
d) ABC/CAB 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.
12. 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’)
13. 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’)

25
14. 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.
15. 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.
16. TELEMONITORING: - TO CONTINUE AS PER PRESENT PRACTICE.
Date
Name
Inv
Time
Sign – Symptom -Treatment
B
Blood
Pressure
P
Pulse
T
Temp
S
Stool
Urine
In/Ou
t
V
Vomitin
g
A
Ane
mia
J
Jaundic
e
C
Che
st
C
CVS
H
Headac
he
C
Convln
Comma
Treatment
20-12-09
CtKeshavDas
PF+ve
6AM
138/82 94
102Chill
Sweating
24
clear
Red
1000/8
50
++ - ++ ++ - ++ - Inj
Artisunate
00-00-0
Tab
Random-D
Glucose
6PM
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)

27
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 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

28
(DDT SPRAY) APPX ‘A’
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. Field 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.
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.
1. Stirrup pump/back up 02 6. Pump washers 02
2. Spare nozzle tip for pump 01 7. Measuring mug 01
3. Bucket 15 litters 04 8. Straining cloth (Mtr) 01
4. Bucket 5/10 litters 01 9. Plastic sheet 3X3 Mtr 01
5. Asbestos thread (Mtr) 03 10. Soap 01

29
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 in 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.

30
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.
YOU ARE ENTERING
“MALARIA PRONE ZONE”
SUN DOWN – SLEEVE DOWN

31
APPX ‘D’
HOW TO RECOGNISE THE DANGER SIGNS
(Criteria for immediate referral to Primary Health Centre/ Hospital)
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 convulsions, fits or muscle twitching?
• Does the patient vomit repeatedly & inability to retain oral drugs?
• How much urine does the patient pass? No urine? Very little? Dark urine?
2. LOOK
• Is the patient abnormally sleepy, difficult to wake? or
• Has the sensorium changed e.g confusion, drowsiness, blurring of vision,
photophobia, disorientation?
• Does the patient have pallor (Suspicion of severe anaemia)?
• Does the patient have dehydration –(dry, parched skin, sunken face)?
• Is the patient unable to stand or sit. Is he too weak to walk in the absence of
any other obvious reason?
• Is the patient having Bleeding and Clotting disorders?
• Is the patient having Jaundice?
• Is the patient having Hypothermia?
* 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.

32
APPX ‘E’
TREATMENT & 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
TransfusionNo
ImprovementImprovement
in Output
Continue Treatment
Antibiotics,
Fluids,
Inotropic
No
Improvement
Restrict
IV
Oxygenation
Refer to Higher Centre

33
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.

34
B -Breathing
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.

36
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 :
2.6.3 Name of the medical institution where referred :
The investigation should be carried out by Medical Officer. Any Investigation carried out by a
person other than Medical officer will not be valid

37
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.

38
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.

39
- 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 __________

40
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

41
........ / .......... /.......... ........ / .......... /..........
........ / .......... /.......... ........ / .......... /..........
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:..............................................................................................................................................................................................................................................................

42
........................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................
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;
• treatment, whether hospitalized and outcome.
4. Investigate and collect data about the suspected drug(s):

43
• 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).

44
MONTHLY REPORT RETURN FORMAT APPX ‘I’
MALARIA AMONGST TROOPS & FAMILIES FOR THE M/O ___________20 ___
NameofUnit/HQ
TROOPS FAMILIES
Grand
Total
Fresh
Relapse
Total
Fresh
Relapse
Total
PV PF PV PF PV PF PV PF PV PF PV PF PV PF
MALARIA & OTHER VECTOR BORNE DISEASES FOR THE M/O____________________20___
NAMEOFHQ/UNIT
TOTALCASESTESTEDBY
RDT/MICROSCOPY
TOTALMALARIACASESPV+PF
MALARIAPFCASES
PVCASESTREATEDWITHCQ+PQ
PFCASESTREATEDWITHACT+PQ
SEVERECASEONMALARIA
(INDOORCASESTREATEDWITH
ARTISUNATE/QUININE
DEATHDUETOMALARIAPF/PV
SEPARATALY
DENGUE(ELISACONFIRMEDAS
PERGUIDELINES)
KALAZAR
CHIKENGUNIYASUSPECTED
HIKENGUNIYACONFIRMED
ACUTEENCEPHALITISSYNDROME
(ASPERGUIDELINE)
JAPANESEENCEPHALITIS
(CONFIRMEDBYMCELISA)
FILARIACASESLYMPHOEDEMA/
HYDROCOELSEPARATALY
RD
KIT
MICRO
SCOPY
PV PF
Signed by
[Dr C B Narayan, CMO(SG)]
I/C, Malaria Cell, BSF
CAPF’s
Comp Hospital, Agartala

Upgraded 2020 Malaria Management booklet in English by Dr Narayan

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