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Malaria Case Management at Point of Care 15th RBM Partnership Board Meeting 10th November 2008 A. P. Dash Director National Institute of Malaria Research, Delhi National Institute of Malaria Research Mandate Basic and applied research Test and validate new drugs, vaccines, diagnostics & insecticides Epidemic investigations Networking and linkages. Maintain parasite and vector repositories as a national facility Human resource development Technical support to National Programme. NIMR and Its Field Units DRUG MANUFACTURERS Sanofi Aventis Networking of NIMR Goa Shin Poong Cuttack Emcure Goa AIIMS Ranbaxy Tribal Guwahati Welfare Dept Emcure Jabalpur Downtown NICD CWS Pfizer NVBDCP IGH Birla Hosp. Min of Env Wenlock & Forest State Health TMH DBT Liverpool ISRO DRL US Embassy ICGEB CDC NIH NIV DRDE IISc IOP Morehouse NIMR VCRC CRME NIMS, DMRC RMRCB RMRCTJ RMRC D ICMR INSTITUTES Central Facilities • Malaria Parasite Bank – More than 750 Pf, about 100 Pv, 5 Pm strains, 50+ non human strains • Insectory – NIMR maintains more than ten mosquito species in the insectory • Animal House – The animal facility of NIMR maintains mice, rabbits etc. • Central Instrumentation Facility – Has all the modern equipments including : • • • • • • 96 capillary DNA sequencer LCMS/MS Real Time PCR HPLC Flowcytometer PCR machines etc. • Library – More than 100 journals and 7000 books Malaria case management: Treatment practices • Assessment of malaria treatment practices in Public and Private Health Sector’s (2005-07) • Operational research on drug use practice and prepackaged blister pack drugs (2006-07) • Extent of use of artemisinin monotherapy in malaria endemic states (2008) • Operational research on drug use practice among children in Jharkhand (Initiated) Treatment Practices in Public and Private Health Sector • Study conducted (n=1107) in Low (Delhi), Moderate (Gujarat) and High Endemic areas (Orissa) • Reporting of malaria cases from private sector was low (15-28%) as compared to public sector (48-98%) • Diagnostic facilities (Microscopy) inadequate in Private Sector (14-74%) • Awareness of new diagnostic techniques higher in high endemic state of Orissa (93%) than other states (3866%) • Knowledge about drug policy and treatment guidelines is inadequate – 63-98% in public and 50-77% in private sector Treatment Practices with reference to change in Drug Policy (Jharkhand) Drugs prescribed for treatment of uncomplicated falciparum malaria Medical Officer 100% 80% 60% Artemisinin compounds 40% CQ or SP CQ 20% 0% Angara PHC Silli & Namkum Jaldega PHC Kolebera PHC • Despite change in drug policy in Angara & Jaldega districts, CQ/SP is used • In Namkum recommended drug chloroquine is prescribed • In Kolebera where first line drug is CQ, Artemisinin is prescribed by 50% clinicians % response Prescribing pattern of antimalarials : Use of Artemisinin Monotherapy 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 AS alone CQ SP MQ Am+Lum AS+SP Drug Assam Goa Gujarat Delhi Jharkhand Orissa • 65% clinicians prescribe AS monotherapy • 32% prescribe SP alone • 35% prescribe AS+SP AS+Other Availability of antimalarials across the counter • AS monotherapy available with 77% Availability of Artemisinin Monotherapy in Chemist Shops (n = 493) Not Available 23% chemists Available 77% • 44% chemists sale antimalarials without prescription Antimalarial sold without prescription (n = 493) With prescription 56% Selling without prescription 44% In-Depth Review of National Programme Observations • Complete IRS only in 1.2-17% households • Ownership of mosquito nets 19-88% • Poor surveillance activities • Lack of preparedness for malaria outbreaks • IEC & health education material not available in large no. of health facilities • Blood examination on first day of fever 11-55% Study areas Recommendations • Actions to improve vector control • Improvement in surveillance and epidemic preparedness • Community information and mobilization • Review of constraints in diagnosis and treatment through policy development Conclusions • Knowledge about new drug policy and treatment guidelines inadequate both in public & private sectors • AS monotherapy available & prescribed at all levels • Irrational practices – Antimalarials prescribed even in confirmed negative cases – Injectables used for uncomplicated malaria – Concomitant use of injectable Artesunate & Quinine in severe malaria – Use of Mefloquine/AS in vivax malaria – Incorrect dosing (even in tertiary care level) Recommendations • Increasing awareness – Persistent & repeated effort required through various forums – Short messages / treatment guidelines to be distributed through periodicals • Making prescribed treatment available (ACTs) NIMR-IMA workshop on Malaria & Dengue: September 17, 2008 Thank you