Background

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Based on the Revised Malaria Control strategy of early diagnosis and prompt treatment (EDPT) the then National Malaria Control Program, Bangladesh adopted the treatment regimen in 1994 through a consensus workshop. Since then, the treatment regimen was revised at several occasions. As the necessity arose over the period of time, the national program adopted required changes and updated the malaria treatment regimen. Any revision, whenever it took place, was done through consultation meetings with relevant partners, collaborators and stakeholders and due endorsement was taken.

The treatment guideline, adopted in 1994, was in place until its 1st revision in 2004. By then, there were evidences from several studies on monitoring of antimalarial drug resistance that Chloroquine had been found to be resistant to treatment of Plasmodium falciparum malaria to the extent ranging from 40% to 70% in the high endemic areas of Bangladesh. Besides this, commonly used drugs Fansidar and occasionally used drugs like Mefloquine was found to be resistant. Results of those various drug efficacy studies, as well as accessibility issues, raised concern for the national program. It 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 drugs to ensure radical cure. Therefore, the multidrug resistant status of falciparum malaria treatment had led to the 1st revision of the regimen in 2004.

Based on epidemiological situation and changes in the malaria paradigm, further revision of the malaria treatment regimen was again warranted in 2009. The 2004 version of the regimen adopted treatment as UMC (Uncomplicated Malaria Confirmed), UMP (Uncomplicated Malaria Presumptive) and SM (Severe Malaria) for Plasmodium Falciparum cases and VM (Vivax Malaria) for Plasmodium Vivax cases. But UMP cases were still being treated with Chloroquine. It created many controversies, as this group of patients were receiving ineffective drugs. It virtually did lead to no effective treatment and patients remained at risk of developing severe malaria. By then, field researches, quality data and experiences revealed that diagnosis by Rapid Diagnostic Test (RDT) was within reach and prompt treatment with Artemisinin Based Combination Therapy (ACT) were also easily available at the community level. So, it was decided to discourage UMP and treat malaria cases on confirmatory diagnosis only. The necessary revision had been made in 2009 after reaching at a consensus with all relevant stakeholders. The revised Malaria Treatment Regimen 2009 includes revision of case definition and management of malaria with flow chart.

The further revision in malaria treatment regimen was made in 2014. It was decided to provide single dose of Primaquine (0.75 mg/kg) on 1st day of ACT or Q7T7 /Q7D7 /Q7C7 treatment for Plasmodium falciparum cases. However, it would not be applicable for pregnant women, infants (< 6 months of age) and lactating mother upto 6 months. Again, the dose of Primaquine was revised in 2016 from 0.75 mg/kg to 0.25 mg/kg. The latest revision of malaria treatment regimen in 2017 included the provision of providing ACT at all stages of pregnancy and treating infants weighing < 5 kg for uncomplicated Plasmodium falciparum / Mixed cases with ACT at the same mg/kg body weight target dose as for children weighing 5 kg. The necessary revision had been done in 2017 through a series of consultations with clinicians, public health experts, epidemiologist, program managers and other stakeholders. The 6th version of the revised malaria treatment regimen was also endorsed by the National Malaria Technical Committee.

Objective:

To update and revise the existing Malaria Treatment Regimen in Bangladesh with provision of early definitive diagnosis, prompt and appropriate treatment of cases.

Issues considered:

The following issues were considered during updating:

  • Universal access to early diagnosis (RDT and Microscopy) and provision of prompt and appropriate treatment with ACT
  • Provision of newer effective antimalarial drugs
  • Increased awareness through intensive Behavior Change Communication (BCC)
  • Specific evidences related to diagnosis, treatment and pharmacovigilance
  • Potential partnership for effective service delivery
  • Generating further evidences on safety of newer antimalarial drugs in the first trimester of pregnancy and child <5kg

Malaria Treatment Regimen

Revised Treatment Regimen for malaria has been adapted for:

  • Early Definitive Diagnosis and Prompt Treatment (EDPT)
  • Prevention or delay in development of drug resistance
  • Interruption of transmission
  • Reduction of morbidity and mortality.