Control of malaria

1. CONTROL OF MALARIA

2. APPROACHES TO MALARIA CONTROL Management of malaria cases in the community. Active intervention to control/interrupt malaria transmission with community participation.

3. 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.

4. National Drug Policy on Malaria,2010 National Drug Policy on Malaria was first formulated in 1982 and has subsequently been reviewed and revised periodically.

5. 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

6. 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.

7. Treatment of uncomplicated malaria

8. General recommendations for the management of un complicated malaria Avoid starting Rx on empty stomach., 1 st 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.

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

10. 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

11. 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.

12. Primaquine is used to prevent relapse. Contraindicated in pregnant women, infants and individuals with G6PD deficiency

13. 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

14. 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 

15. Patient resistant to ACT-quinine is drug of choice.

16. SEVERE MALARIA

17. 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

18. SeverE and complicated malaria Choice of antimalarial is quinine injection 10mg/kg body wt. I.V drip in 5% dextrose saline to be runover 4hrs Total 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

19. Artesunate 2.4mg/kg bw IM or IV followed by 1.2mg/kg bw once daily for 4 days Total duration is 5 days Artemether 1.6mg/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 Artemisinine 10mg/kg bw at 0 and 4 hours followed by 7mg/kg bw at 24,36,48 and 60 hours

20. 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.

21. Symptoms may be of three types Plasmocid types Rare toxic manifestation involving the CNS Gastrointestinal Cramps,nausea and vomiting Cardiovascular Most serious toxic menifestation

22. 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 immunity May accelerate devlopment of drugs resistance May increase the risk of retinopathy

23. 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

24. 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.

25. 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

26. Active intervention measures Stratification of problem Essential 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.

27. 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 nets Zooprophylaxis 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

28. Vector control strategy Anti-adult measures Residual spray Spraying indoor surface of house with DDT/ malathion . Discontinuation lead to resurgence of malaria. Reduces the longevity of vector. Space application Major anti-epidemic measure Involves application of pestisidesin the form of fug or mist using special equipments

29. Individual protection Man-vector contact can be reduced by Using nets, protecting cloth, coils, repellents,screening of houses.

30. Anti-larval measure Larvicides O iling 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

31. 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

32. 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

33. 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

34. 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.

35. 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

36. 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 v olunteeers in Belgium, Gambia, kenya and US only potential malarial vaccine

37. Thank you…