1. 15 th RBM Partnership Board Meeting 10 th November 2008 A. P. Dash Director National Institute of Malaria Research, Delhi Malaria Case Management at Point of Care

2. 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.

3. NIMR and Its Field Units

4. Networking of NIMR NIV IOP VCRC CRME NIMS, DMRC RMRCB RMRCTJ RMRC D ICMR INSTITUTES NIMR INDIAN UNIVERSITIES DU Goa RDVV GGS IP Jamia Rohtak Bangalore Sambalpur DRUG MANUFACTURERS Sanofi Aventis Shin Poong Emcure Ranbaxy Emcure Pfizer INSECTICIDE MANUFACTURERS Bayer Vestergaard Reliance Sumitomo Biotech BASF WHO USAID WHOPES MMV DNDi PATH Michigun Uni. NY University INTERNATIONAL AGENCIES HOSPITALS TMH IGH Wenlock CWS Birla Hosp. GOVT. ORGANISATIONS NICD NVBDCP State Health INTERNATIONAL ORGANISATIONS US Embassy CDC NIH MEDICAL COLLEGES Cuttack Goa Jabalpur Goa ICGEB DRDE VACCINE / OTHERS Liverpool Morehouse DBT Min of Env & Forest Tribal Welfare Dept Guwahati Downtown IISc ISRO DRL AIIMS

5. 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

6. 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)

7. 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

8. Treatment Practices with reference to change in Drug Policy (Jharkhand) 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

9. Prescribing pattern of antimalarials : Use of Artemisinin Monotherapy 65% clinicians prescribe AS monotherapy 32% prescribe SP alone 35% prescribe AS+SP

10. Availability of antimalarials across the counter AS monotherapy available with 77% chemists AS monotherapy available with 77% chemists 44% chemists sale antimalarials without prescription 44% chemists sale antimalarials without prescription

11. 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

12. 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

13. 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)

14. 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

15. Thank you