1. Drug Policy Bangladesh Presented by Dr ATM Mustafa Kamal National Programme Manager Malaria and Vector Borne Disease Control DGHS, Dhaka, Bangladesh

2. Malaria Situation in Bangladesh Country Area 147,570 sq. km and Pop. 133.4 million 13 out of 64 districts are high endemic 14.7 million people are at high risk 60,000 - 75,000 lab confirmed cases per year Estimated 1.0 million clinical cases annually Focal outbreaks in eastern border are not infrequent Drug resistance (CQ,SP) reported in CHT.

3. Drug Policy Bangladesh Drug policy refers to a set of recommendation and regulations concerning antimalarial drugs which requires: Continuous evaluation Regular review Updating

4. It will harmonize with the corresponding policies of neighboring countries. Objective :To ensure prompt, effective and safe treatment of malaria through selection of optimal regimen for different clinical situation

5. National drug policy making body The Directorate of Drug Administration is the apex body; For formulation of national antimalarial drug policy WHO guidelines are strictly followed; Bangladesh has a National Drug Policy.

6. Previous drug policy In 1994 Revised Malaria Control Strategy was adopted by Bangladesh (as per the Ministerial Conference in Amsterdam-Malaria Declaration). Adoption: Clinical Case Definition- Uncomplicated Malaria; Treatment failure malaria and Severe Malaria.

7. Uncomplicated Malaria UM cases were treated with chloroquine (dose= 25 mg/kg body weight) in 3 days regimen followed by primaquine, a single dose (45 mg)

8. Treatment failure Malaria Treatment failure malaria cases are treated with Quinine (10 mg/kg body weight) for 3 days followed by: primaquine in a single dose (45 mg) and Fansidar (SP) 3 tablet single dose.

9. Severe Malaria Parental quinine (quinine dihydrochloride =10 mg/kg body weight) followed by oral quinine (Total 7 days).

10. Drug resistance The degree of drug resistance of P. falciparum to chloroquine and SP are increasing particularly in the high endemic areas (Myanmar and India Border districts).

11. A randomized control trial in one of the high risk malarious area has yielded. Case study-I Drug-Chloroquine Ramu upazila/Cox’s Bazar Total Pop. in study area-188812 RI-22%, RII-16%,RIII-40% ETF-34%,LTF-33%,ACPR-34%

12. Case study-II Teknaf Upazila/Cox’sBazar Drug-Chloroquine Total Pop. in study area-18500 ETF->25% LTF->25%

13. Case study-III Sreemongal UZHC Moulavibaza District Drug- Chloroquine Pop. in study area –271000 (Year-1999) ETF->25% LTF->25%

14. Case Study-IV Ramu upazilla Cox’s Bazar District Drug-Q3+SP Total Pop.in study area –188812(Year- 1997) RI-22%,RII-2%,RIII-6% ETF-O%, LTF-21%, ACR-79%

15. Study-V Ramu Upazila, Cox’s Bazar Drug-Mefloquine Total Pop. in study area-188812 (Year-1997 RI-13%, RII-4%, RIII-10% ETF-0%, LTF-11%, ACR-89%

16. Study-VI Kaptai Upazila, Rangamati Drug-CQ3+SP ETF-2.9% LPF-30% ACPR-67.1%

17. Study-VII Dhiginala Upazila, Khagrachari Drug-CQ3+SP ETF-4.3% LCF-7.1% LPF-1.5% ACPR-87.1%

18. Study-VIII Fatikchari Upazila, Chittagong Drug-CQ3+SP ETF-4% LCF-16% LPF-2% ACPR-76%

19. Case Study-IX Matiranga Upazila/Khagrachari Drug-CQ3+SP ETF-7.7% LCF-9.2% LPF-13.8% ACPR-69.3%

20. Case Study-X Alikadam Upazila, Bandarbar District Drug-CQ3+SP ETF-3.5% LCF-20.7% LPF-1.7% ACPR-74.1%

21. Case Study-XI Chittagong Medical College Drug-AS Vs Quinine Artesunate mortality-52/222(23%) Quinine mortality-75/231(32%)

22. Based on drug resistance status GoB approved new antimalarial treatment regimen and introduced Atimisinin based Combination Therapy (ACT). 10 November 2004 Revised Malaria Treatment Regimen adopted by MOHFW.

23. Revised Malaria Treatment Regimen Malaria Case Definition Uncomplicated Malaria Presumptive(UMP) Uncomplicated Malaria Confirm (UMC) Severe Malaria (SM)

24. Uncomplicated Malaria Presumptive Fever or h/o fever over last 48 hours; Absence of convincing features of any other febrile illness; High index of suspicion, Endemic zone, susceptible population, transmission season; Without microscopy or RDT.

25. Uncomplicated Malaria Confirm Fever or h/o fever over last 48 hours; Absence of convincing features of any other febrile illness; High index of suspicions ： Endemic zone, susceptible population ， Transmission season Presence of asexual form of P. falciparum

26. Severe Malaria Fever or H/o fever over last 48 hours; With one or more feature of severity; Presence of asexual form of P. falciparum in blood slide examination or +ve RDT

27. Revised Malaria Treatment Regimen Uncomplicated Malaria presumptive: UMP cases should be treated with Chloroquine for 3 days Blood slide or RDT should be done, As soon as possible.

28. Uncomplicated Malaria Confirm For P.falciparum: Artemether+lumifantrin - for 3 days Quinine for 7 days in special and specific situation Quinine-7 days+TC-7days or Quinine-7days+Dc- 7days For P. vivax CQ for 3 days and primaquine- for 14 days.

29. Severe malaria IV/IM Quinine followed by oral Quinine-7 days AM/Artesunate in selected cases IM Quinine/Rectal artesunate (?) in pre-hospital treatment Immediate referral should be made

30. Thank You