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Dr. P.N. Sehgal, currently a Consultant to
the Voluntary Health Association of India, is a former
Director of the National Institute of Communicable
Diseases, New Delhi Voluntary
Health Association of India (VHAI) conducts orientation
courses for Private Medical Practitioners in early
diagnosis, treatment and clinical management of malaria
cases. It has been observed that there is lack of
awareness among medical professionals about rational
therapeutic aspects of the disease. This situation is
leading to untimely exposure of the malaria parasites to
newer drugs, and because of continued and multiple drug
pressure, they are prone to develop drug resistance.
Chemoprophylaxis in the endemic area and presumptive
treatment to any fever cases are to be looked into
seriously in regard to their role in the emergence of
chloroquine resistance.
Use of Mefloquine
The indiscriminate use of the new anti-malarial
drug - Mefloquine - is a cause of great concern. A
Committee of medical experts, constituted by the
Directorate General of Health Services in 1995, to review
the National Drug Policy on Anti-malarials made the
following recommendations:
"P.falciparum
can be cured with the already available anti-malarials,
provided the treatment is not delayed and supportive
therapy is started in time. However, in the light of the
demand made by the medical fraternity, Mefloquine can be
used for treatment of P.falciparum cases resistant to
chloroquine only and not for treatment of P.vivax cases.
Therefore, it is recommended that the Drugs Controller of
India may stipulate strict conditions for import, sale
and use of Mefloquine through a depot system where:-
- It should be
mandatory that the drug is issued only on
prescription by a qualified registered medical
practitioner;
- The prescription
should be accompanied by a laboratory report
issued by a qualified parasitologist indicating
that there are P.falciparum rings in the
peripheral blood and not gametocytes alone".
It is therefore, strongly
emphasized that the above mentioned recommendations of
the Committee must be followed strictly by the Drugs
Controller of India and the States Drugs Controllers.
The other concerns
about Mefloquine are:
- In practice, in the
Indian situation, it is not possible to comply
with the condition of a "compulsory
laboratory report" by a qualified
parasitologist indicating that there are
P.falciparum rings, as per the recommendation of
the Committee.
- Cross resistance with
quinine develops rapidly, so loss of
effectiveness of quinine due to Mefloquine misuse
especially when P.falciparum infection are
increasing in the country, could lead to a major
public health catastrophe. Technically Mefloquine
has no advantage over other available
anti-malarials effective for P.falciparum.
- As the gametocytes
are not killed by Mefloquine, a patient treated
with Mefloquine will remain a reservoir of
infection, spreading the infection in the
community, and will be a public health danger.
- Mefloquine is not
recommended by the Center for Disease Control
(CDC), Atlanta (USA) for standby treatment in any
situation. Breast-feeding by mothers taking
Mefloquine is contraindicated. Terotogenicity in
animals has been noted and, therefore, it should
be avoided in the first trimester. It is
contraindicated for those with history of
convulsions, psychiatric disorders, severe renal,
hepatic dysfunction and cardia conductive
disorders.
Taking all the factors
into consideration, the introduction of Mefloquine has
only facilitated unethical medical practice and promoted
misuse/over use of a drug that should be kept restricted
for use as the only second line against chloroquine
resistance. Therefore Private Medical Practitioners need
to be oriented for the restricted rational use of
Mefloquine as per the recommendations of the Expert
Committee.
Rational use of
Anti-malarials
Following suggestions are
made for an effective and rational Drug Policy on
Anti-malarials:-
- The results of the
Drug resistance monitoring must be made available
to the district health authorities as well as to
the medical professionals in the respective
areas.
- Adverse drug reaction
monitoring of old/newer anti-malarials should be
undertaken and post-marketing surveillance by
manufacturers of newer anti-malarials should be
ensured.
- Glucose
6 Phosphatase Dehydrogenase (G6PD) deficiency and
sickle cell anemia mapping should be done and
made available to doctors in the affected region
with warnings about anti-malarials and other
drugs to be avoided.
- Proper prescription
audits, medical audits and drug audits must be
undertaken periodically and in-house prescription
audits should be encouraged.
- In endemic areas,
anti-malarials should be made available free of
cost or at reasonable prices.
- Specialized centres
for the treatment of severe and complicated
malaria cases should be established in teaching
hospitals of medical colleges and in all district
hospitals of endemic areas.
- National Malaria
Eradication Programme (NMEP) should publish its
guidelines (at least once a year) on
drugs/dosages/precautions/indications and
contra-indications to scientific
publication/guides which are routine reference
for practitioners. These guidelines should also
be incorporated into medical (undergraduate and
postgraduate) training as well as in the courses
for nursing and allied health professionals.
- NMEP should pursue
vigorously its policy of involvement of NGOs for
continuing medical education and orientation of
private medical practitioners in rational
clinical management of malaria.
References
1. Towards an Appropriate Malaria Control
Strategy; VHAI, 1997.
2. Drug Policy on Malaria; NMEP Directorate, 1995.
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