1515thth RBM Partnership Board Meeting RBM Partnership Board Meeting1010thth November 2008 November 2008

1515thth RBM Partnership Board Meeting RBM Partnership Board Meeting1010thth November 2008 November 2008

A. P. DashDirector

National Institute of Malaria Research, National Institute of Malaria Research, DelhiDelhi

Malaria Case Management at Point of Care

National Institute of Malaria Research

Mandate

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 UnitsNIMR and Its Field Units

Networking

of NIMR

NIV

IOP

VCRC

CRME

NIMS, DMRC

RMRCB

RMRCTJ

RMRC D

ICMR INSTITUTES

NIMR

INDIAN

UNIVERSITIES

DU Goa RDVV GGS IPJamia

RohtakBangalore

Sambalpur

DRUG MANUFACTURERS

Sanofi Aventis

Shin Poong

Emcure

Ranbaxy

EmcurePfizer

INSECTIC

IDE

MANUFACTURERS

Bayer

Vestergaard

Reliance

Sumitomo

Biotech

BASF

WHO

USAID

WHOPES

MMV

DNDi

PATH

Michigun Uni.

NY Univers

ity

INTERNATIO

NAL

AGENCIES

HO

SP

ITALS

TMHIGH

Wenlock

CWSBirla Hosp.

GO

VT.

OR

GA

NIS

ATI

ON

S

NICDNVBDCP

State Health

INT

ER

NA

TIO

NA

L

OR

GA

NIS

AT

ION

S

US Embassy

CDC NIH

MEDICAL COLLEGESCuttackGoa

Jabalpur

Goa

ICGEBDRDE

VA

CC

INE

/

OT

HE

RS

Liverpool

Morehouse

DBT

Min of Env & Forest

TribalWelfare Dept

GuwahatiDowntown

IISc

ISRO DRL

AIIMS

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 pre-packaged 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 (38-66%)

• 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)

0%

20%

40%

60%

80%

100%

Med

ical

Offi

cer

AngaraPHC

Silli &Namkum

JaldegaPHC

KoleberaPHC

Drugs prescribed for treatment of uncomplicated falciparum malaria

Artemisinin compounds

CQ or SP

CQ

• 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

Prescribing pattern of antimalarials : Use of

Artemisinin Monotherapy

0.010.020.030.040.050.060.070.080.090.0

100.0

AS alone CQ SP MQ Am+Lum AS+SP AS+Other

Drug

% r

espo

nse

Assam Goa Gujarat Delhi Jharkhand Orissa

• 65% clinicians prescribe AS monotherapy• 32% prescribe SP alone• 35% prescribe AS+SP

Availability of antimalarials across the counter

Availability of Artemisinin Monotherapy in Chemist Shops (n = 493)

Not Available

23%

Available77%

Antimalarial sold without prescription(n = 493)

Selling without

prescription44%

With prescription

56%

• AS monotherapy AS monotherapy

available with 77% available with 77%

chemistschemists

• 44% chemists sale 44% chemists sale

antimalarials without antimalarials without

prescriptionprescription

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