Transcript Slide 1

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 :
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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