The Revised Malaria Treatment Regimen 2004

Public Health & WHO and Ministry of Health & Family Welfare
Department Of Medicine
Ibn Sina Medical College
09.08.09

Objective:
To update the current recommendation for diagnosis and treatment
of malaria in Bangladesh with provision for early definitive diagnosis,
prompt and appropriate treatment (EDPAT) of the cases.

Background:
Based on the universal principles of Early Diagnosis and Prompt
Treatment (EDPT) the National Malaria control Program in Bangladesh
adopted the Treatment regimen 1994. This was done through a consensus
workshop held in BARD, Comilla in December 1994. On the basis of the
evidence from various studies on drug efficacy and accessibility issues
that are the concern of National Malaria Control Program; it has been
deemed necessary to update the Malaria Treatment Regimen and related
operational issues for providing treatment of all malaria cases in the
endemic areas of Bangladesh with effective to ensure radical cure.
It has been evident from several studies on Monitoring of Anti-
malarial drug Resistance that Chloroquine has been found to be resistant
for treatment of Plasmodium falciparum malaria to the extent ranging
from 40%-70% in the high endemic malaria areas of Bangladesh.
The National Malaria Control Program along with all relevant
partners and collaborators arranged a consultative meeting on 13 th march
2004 to review and update the current malaria treatment regimen and
arrived at a consensus for a Revised Malaria Treatment Regimen to be
adopted n Bangladesh.
The Draft Revised Malaria Treatment Regimen was further reviewed
by a technical Sub-Committee and submitted through the Director
General of Health Services, to the Ministry of Health & Family Welfare
for endorsement.
A meeting was convened under the Chairmanship of Joint Secretary,
Public Health & WHO, and Ministry of Health & Family Welfare on 3rd
October 2004 for further review of the Draft Malaria Treatment Regimen.
The meeting approved the new treatment regimen 2004.

Rationale for Updating the Malaria Treatment Regimen

In previous national guideline adopted in 1994 three malaria
clinical case definition of Uncomplicated Malaria (UM), Treatment
Failure Malaria (TFM), & Severe Malaria (SM) were given but as
Choloroquine is becoming resistant to falciparum malaria the
 The Revised Malaria Treatment Regimen 2004

treatment of UM according to1994 guideline is not acceptable at

present situation because of chance of development of severe
malaria. So for early diagnosis & effective Treatment following
classification was adopted:
1. Uncomplicated Malaria Confirmed (UMC):
• Fever or History of fever within last 48 Hours.
• Absence of convincing evidence of any other Febrile
illness,
• High index of suspicion,
• Diagnosis is confirmed by Blood Slide Examination
(BSE) or Rapid Diagnostic Test (RDT) Positive for
Plasmodium falciparum.

2. Uncomplicated Malaria Presumptive (UMP):

• Fever or History of fever within last 48 Hours.
• Absence of convincing evidence of any other Febrile
illness,
• High index of suspicion,
• Non availability for confirmation: BSE/RDT.
• Effort should be made to confirm the case as UMC
3. Severe Malaria (SM)
• Fever or History of fever within last 48 Hours.
• With one or more of the following features of severity
- A change of behavior, confusion & drowsiness,
- Altered consciousness & coma (cerebral
malaria),
- Generalized convulsion >2 episodes in 24
hours,
- Hypoglycaemia (<2.2 mmol/L or <40mg/dl),
- Acidosis,
- Difficulty in breathing or acute pulmonary
oedema & ARDS,
- Oliguria or acute renal failure (<17ml/hour 0r
<400ml/day),
- Severe Anaemia (Haematocrit <15%, Hb
<5g/dl),
- Fluid and electrolyte disturbance,
- Circulatory shock or collapse (Algid Malaria),
- Haemoglobinuria,
- Jaundice (clinical),
- A bleeding tendency,
- Severe prostration i.e. extreme generalized
weakness so the patient cannot walk, stand or
sit without assistance & in case of small unable
to eat
- Severe vomiting leading to non per os
Revised by: Md. Baha Uddin (ISMC- 2
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 The Revised Malaria Treatment Regimen 2004

-
Hyper parasitaemia &
Presences of asexual form of P. falciparum in
-
BSE or positive RDT.
4. Vivax Malaria (VM)
• Fever or History of fever within last 48 Hours.
• Absence of convincing evidence of any other Febrile
illness,
• High index of suspicion: endemic zone, susceptibility
population, Transmission season etc.
• Diagnosis is confirmed by Blood Slide Examination
(BSE) or Rapid Diagnostic Test (RDT) Positive for
Plasmodium vivax.

Treatment Recommendations
The revised Malaria treatment regimen should be
implemented with immediate effect & universal access to treatment
to be ensured for radical cure of all malaria patients in the public &
private sectors.

The National Malaria Control Programme in DGHS should take

necessary measures to adapt relevant Diagnosis & Treatment charts etc,
(both English & Bangla) in line with the revised malaria treatment regimen
&orient service providers accordingly. Attempts should be taken for
enhancing laboratory diagnosis capability in both public & private sectors.

National Malaria Control Programme should have appropriate

mechanism for regular information collection, archiving & dissemination of
information on Revised Malaria Treatment Regimen and should be
incorporated in UMIS (Unified Management Information System).

The revised Treatment regimen for malaria is adapted for:

• Early diagnosis end effective treatment of uncomplicated
malaria
• To prevent drug resistance
• To reduce the mortality in severe malaria
• To reduce the morbidity in severe malaria.

Revised Malaria Treatment Regimen

The Revised Malaria Treatment Regimen as per case definitions
should be as follows:
1. Uncomplicated Malaria (UMC):
• The drug should be depending on the species which are as
follows:
 For P. falciparum-
• 1st line treatment: Artemethur + Lumefantrin
combination (Coartem)- 6 divided doses over

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 The Revised Malaria Treatment Regimen 2004

3days (Age & body weight based dose schedule is

given in Annexure)
If for any reason Coartem cannot be given then
• 2nd line treatment: Quinine for 7 days.
The 1st & 2nd line treatment can be alternatively used if
there is failure of any resime.
If failure occurs after use of both Quinine & Coartem
schedule or if after using Quinine for 7days Coartem can not
be used for any reason, then
• 3rd line treatment: Q7+T7 or Q7+D7
[N.B.-1 7 days of oral Quinine will be followed by 7 days of
Tetracycline or Doxycycline in case of 2nd line treatment failure.
N.B.-2 7 days of oral Quinine & 7 days of Tetracycline will be
given simultaneously in case of 1st line treatment failure].
 For P. vivax malaria-
If BSE &/or RDT is positive for P. vivax then it should be
labeled as P. vivax case but it should not be included in
UMC. In this case-
• Chloroquine 3 days + Primaquine 14 days
(CQ3+PQ14).
Dose Schedule:
1st day: 10 mg/kg (4 tabs for Adult);
2nd day: 10 mg/kg (4 tabs for Adult);
3rd day: 5 mg/kg (2 tabs for Adult).

2. Uncomplicated Malaria Presumptive (UMP):

The drugs should be Chloroquine -3 days but all efforts should
be made for confirming the diagnosis as soon as possible by
Blood Slide Examination (BSE) or RDT.

3. Severe Malaria:
 Pre referral treatment:
• IM Quinine/Rectal Artesunate when available
should be used as pre referral treatment in
community.
• Immediate referral should be made to the nearest
health facility where parenteral treatment is
available.
 Hospital Treatment:
• IV Quinine drip / IM Quinine followed by oral
Quinine for upto 7 days.
• Loading dose of Quinine should given.
• IM Artemethur / IV Artesunate can be used as
alternative.

4. Malaria in Pregnant women:

Revised by: Md. Baha Uddin (ISMC- 4
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 The Revised Malaria Treatment Regimen 2004

UMC:
1st trimester: In case of P. falciparum infection Quinine for 7
days.
2nd & 3rd trimester: In case of P. falciparum infection
Coartem.

UMP:
CQ3 in all trimester but efforts should be adopted for
continuing the diagnosis as soon as possible by Blood Slide
Examination or RDT.

SM:
• IV Quinine drip / IM Quinine followed by oral Quinine for upto
7 days.
• Loading dose of Quinine should given.
• IM Artemethur / IV Artesunate can be used as alternative
but preferably should not be used in 1st trimester.

Rationale for the use of other drugs available in the

market
 Chloroquine: As failure is high, it should not be use in UMC cases.
 Fansidar: Due to drug side effects & high failure rate it should not be
used in UMC cases.
 Mefloquine: A highly efficacious drug for P. falciparum but is not
recommended to be used as asingle drug.
 Artesunate: Highly effective for P. falciparum but single drug use is
not recommended due top chance of development of resistance.
 Artesunate & Mefloquine Combination: Highly effective for P.
falciparum.

Implementation of treatment guideline:

1. Definitive diagnosis of malaria should be made available at the
community level.
2. RDT should be the method of choice for definitive diagnosis at
the community level.
3. Static health services should be use Microscopy or RDT for
definitive diagnosis.
4. UMP should be discouraged but still to be used to prevent delay
in starting the treatment.
5. All patients who have received treatment for UMP should report
to nearest health facilities for follow-up.
6. Provision of IMQ to community health workers for use as pre
referral treatment in case of severe malaria. So community
health workers should be given training to recognize SM by
symptoms & to use pre-referral IMQ.

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 The Revised Malaria Treatment Regimen 2004

7. All health care providers (Govt./Non-govt./Traditional

healers/Quack) should be given training to us revised treatment
guideline.
8. Specific education of the patient regarding completion of
treatment should be emphasized during training for prescribers &
dispensers to avoid incomplete doses of Coartem.
9. Pregnant women in absence of effective & safe
chemoprophylaxis alternative method of prevention
(Impregnated bed net and personal protection) should be
promoting.

Revised by: Md. Baha Uddin (ISMC- 6

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