Preamble

Malaria is one of the major public health problem of the country. Around 2 million laboratory confirmed cases of malaria are reported in the country annually. Out of the total malaria cases, 40-50% is P. falciparum. The P. falciparum species is spreading wider due to migration of population from endemic to non endemic areas and vis-à-vis has increased tremendously. One of the reasons attributed to rise in P. falciparum is resistance to drug chloroquine, which is being used as a first line of treatment for malaria cases. During recent years it has been observed that chloroquine resistance is widely spread as per the results of the drug sensitivity studies conducted. This is a serious concern to the programme as this species is responsible for mortality. It is observed that P. falciparum infection may lead to complications in 0.5% to 2% of cases. Mortality may result in about 30% of such cases if timely treatment is not given. Use of an appropriate malaria drugs is very important not only to save the life in P. falciparum cases but also to contain the spread of this species.

At present the main thrust in the programme is on early diagnosis and prompt treatment which are the key components of malaria control. Malaria diagnosis is carried out by microscopic examination of blood films collected by active and passive agencies. The presumptive treatment (chloroquine at a dose of 10 mg/kg body weight ) is given at the time of blood smear collection and radical treatment (chloroquine at a dose of 25 mg/kg body weight + primaquine as per the species) to confirmed malaria patients on microscopy confirmation. The treatment schedule varies from area to area depending on endemicity and status of resistance to antimalarials. The WHO Technical Advisory Group on Malaria in its meeting held in India on 15-17 December 2004 has recommended that the member countries should be discouraged from implementing presumptive, single dose and incomplete treatment with Chloroquine. If a patient is suspected of having malaria which cannot be immediately confirmed, full treatment with recommended drugs should be given. Health Agencies and volunteers running Fever treatment in inaccessible areas should be provided with Rapid Diagnostic Kits for diagnosis and to ensure full Radical Treatment to confirmed Malaria Cases. Priority for treatment should be given to clinically suspected cases rather than on the basis of only fever. Further, the WHO Malaria Treatment Guidelines also recommend that Antimalarial Treatment Policy should be changed when Treatment failure rates are considerably lower i.e. the initiation of alternative treatment regimen at the treatment failure proportion exceeds 10% The reasons attributed for implications of using drugs with low efficacy is that once the drug resistance has emerged in a locality, the continued use of the failing drug will result in the rapid spread of drug resistance in the area.

According to WHO : An Antimalarial Treatment Policy is a set of recommendations and regulations concerning the availability and rational use of Antimalarial drugs in a country. It should be the part of National essential drug policy and the National Malaria Control Policy and in line with the overall National Health Policy.

The main purpose of National Anti Malaria Drug Policy is to provide a frame work for the safe and effective treatment of uncomplicated and sever malaria as well as prevention of malaria in travelers vulnerable groups such as pregnant women and young children . All Health Care Providers in both the public & private sectors must be aware of, understand the rational for and implement the National Anti Malaria Drug Policy.

An effective treatment Policy should aim to :

	Reduce morbidity
	Prevent the progression of uncomplicated diseases into sever and potentially fatal disease and thereby reduce malaria mortality.
	Reduce the impact of placental Malaria infection maternal malaria associated anaemia through Chemoprophylaxis or prevent intermittent therapy.
	Prevent or delay the development of antimalarial drug resistance by correct diagnosis and rational treatment of all malaria positive cases.

National Anti Malaria Drug Policy was first drafted in 1982. Thereafter the Policy is being reviewed periodically by the expert Committee on Chemotherapy on malaria constituted by Director General Of Health Services. The recommendations of this Committee are being ratified by the Technical Advisory Committee constituted by the MOH & FW under the Chairmanship of Director General of Health Services. The present National Drug Policy for Malaria has been framed keeping in view of proper deployment of effective antimalarial drugs and its judicious use for the treatment of clinically suspected and confirmed malaria cases.

Management of Malaria cases:

	Clinically diagnosis of malaria on the basis of signs and symptoms.
	Confirmation of malaria by laboratory diagnosis/ RDT.
	Referral to secondary, tertiary level of care if necessary.
	Education of patient for family on : i) Administration of the drugs ii) When to report to Health Facility iii) Danger symptoms iv) Prevention of Malaria
	Dispensing the correct drugs of assured quality (first dose be given preferably by Dispensary).
	Patient compliance as per instructions

Signs & Symptoms

Typical: Sudden onset of high fever with rigors and sensation of extreme cold followed by feeling of burning leading to profuse sweating and remission of fever by crises thereafter. The febrile Paroxysms occur every alternate day. Headache Body ache nausea etc. may be associated features.
Atypical : In a typical cases, classical presentation as mentioned above may not manifest. Hence any fever cases in the endemic areas during transmission season may be considered as malaria.

Anti malaria drugs

1) Schizonticidal drugs for clinical and parasitological cure.
Chloroquine, Amodiaquine Quinine, Quinidine, Pyrimethamine, Trimethoprim Proguanil, Sulfonamides in combination with Pyrimethamine, Mefloquine, Halofantrine, Artemisinine and its derivatives like Artesunate, Artemether, Arteether.

2) Gametocytocidal and anti-relapse drugs.
Primaquine, B-Aminoquinolines groups, only compound having action on gametocytes and Hypnozoites.