Malaria- A Review of Recent Guidelines in the Indian Context

With around 1.5 million confirmed cases reported annually, malaria is one of the major public health problems of our country. Globally there are at least 300-500 million cases of malaria each year and more than 1 million people die from it.

Malaria is a parasitic disease that is passed from one human to another by the bite of infected Anopheles mosquitoes. This potentially fatal disease is curable if effective treatment is started early. About 50% of the cases reported in our country are due to Plasmodium falciparum. A milder, rarely fatal form of malaria is produced by P. vivax. The malaria caused by P. falciparum is serious; any delay in treatment may lead to consequences including death.

Chloroquine used to be the one drug that cured nearly all cases of malaria in the past.  Drug resistance emerged as a major problem; an increasing frequency of chloroquine-resistant P. falciparum malaria has been observed in recent studies. Continued use of chloroquine without considering the growing resistance may be one the prime factors that caused increased proportion of P. falciparum relative to P. vivax.

In the light of the threat posed by increasing chloroquine resistance, the Ministry of Health and Family Welfare, Govt. of India adopted a revised National Drug Policy on Malaria in 2010.

Symptoms and Signs

Fever is the cardinal symptom of malaria. Many cases have chills and rigors. The fever is often accompanied by features like:

·        Headache

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·        Muscle pain

·        Joint pain

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·        Loss of appetite

·        Nausea

·        Vomiting

The symptoms of malaria can be non-specific and mimic other diseases like viral infections, typhoid etc. The following features, if present, may point to other common infectious diseases and help to rule out malaria:

·        Running nose, cough and other signs of respiratory infection

·        Diarrhea/dysentery (severe diarrhea with blood and mucus)

·        Burning pain during urination and/or lower abdominal pain

·        Skin rash/infections

·        Abscess: Localised collection of pus

·        Painful swelling of joints

·        Ear discharge

·        Swellings caused by enlarged lymph nodes

Microscopy of blood smears remains the gold standard for confirmation of diagnosis of malaria. Unfortunately, a large number of areas lack proper facilities that allow fast microscopic results. Lack of laboratory facilities that provide results within a day deprive patients of the benefits of early diagnosis and treatment such as:

·        Complete cure

·        Prevention of progression of uncomplicated malaria to severe disease

·        Prevention of deaths

·        Interruption of transmission

·        Minimizing risk of selection and spread of drug-resistant parasites

Rapid Diagnostic Tests (RDTs) are available to aid areas inaccessible to lab facilities. RDTs can detect circulating parasite proteins called antigens. RDT kits for detection of P. falciparum are supplied by the National Vector Borne Disease Control Programme (NVBDCP) at locations where microscopy results are not obtainable within 24 hours of sample collection.

RDT kits are produced by different companies. Meticulous inspection of the kit is required to ensure that results obtained are accurate. It is the responsibility of the health care personnel doing a rapid test for malaria to ensure that the RDT kits are usable, i.e. the kit is within its expiry date and has been transported and stored under recommended conditions. Careless usage will lead to false results.

Treatment

Treatment depends upon the underlying parasite. Drug therapy is modified depending on the test results. The dosages of drugs are based on the weight of the person.

Chloroquine and Primaquine are the two drugs used once the species causing malaria has been confirmed to be P. vivax. A combination regimen can called Artemisinin Combination Therapy (ACT) is given to all confirmed P. falciparum cases found positive by microscopy or RDT. This is accompanied by a single dose of primaquine.

A number of drugs like artesunate, artemether are derived from artemisinin, the key ingredient obtained from Artemisia annua. In ACT, an artemisinin derivative is combined with a long acting antimalarial drug like amodiaquine, lumefantrine, mefloquine or sulfadoxine-pyrimethamine.

Treatment of malaria in pregnancy involves the use of quinine, ACT and chloroquine. ACT should be given for treatment of P. falciparum malaria in second and third trimesters of pregnancy, while quinine is recommended in the first trimester. P. vivax malaria can be treated with chloroquine.

The following general guidelines are recommended for uncomplicated malaria:

·        Avoid starting treatment on an empty stomach.

·        Dose should be repeated if vomiting occurs within 30 minutes.

·      Report back to the doctor, if there is no improvement after 48 hours or if the situation deteriorates.

·        The patient should also be examined for concomitant illnesses.

In-patient management is warranted in severe cases of malaria. Fluids through a vein (IV), other medications and breathing (respiratory) support may be needed in such cases.

Severe cases of P.vivax should be treated like severe falciparum malaria.

Prevention

Travellers, migrant labourers and military personnel exposed to malaria in highly endemic areas are recommended to take drugs for chemoprophylaxis, for the purpose of prevention. Doxycycline and Mefloquine are the two drugs used for this purpose. Use of personal protection measures like insecticide-treated bed nets should be encouraged for pregnant women and other vulnerable populations.

Prognosis

Most of the cases of malaria cure completely on treatment, while Falciparum infection with complications has a poor outcome. Falciparum malaria can produce fatal complications affecting the brain. Failure of kidney, liver, respiratory system, massive destruction of blood cells, rupture of the spleen can all occur as complications. Prompt diagnosis and treatment of malaria is vital and saves lives.

Reference: Guidelines for diagnosis and treatment of malaria in India, 2011: National Vector Borne Disease Control Programme (NVBDCP), National Institute of Malaria Research.

Source-Medindia