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Archived Comments for: Impact of community-based presumptive chloroquine treatment of fever cases on malaria morbidity and mortality in a tribal area in Orissa State, India

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  1. Presumptive Treatment: A step backward

    Neena Valecha, National Institute of Malaria Research

    9 June 2008

    Neena Valecha* and A M Reetha (NIMR)

    *Corresponding author

    We agree with the concept of early diagnosis and treatment which is emphasized by Das et al, (2008). However, presumptive treatment for low risk areas with chloroquine in the single dose of 10mg/ kg and with 25mg/kg over 3 days and single dose of Primaquine viz 0 .75 mg/ Kg on the 1st day in high risk areas was recommended according to guidelines of National Drug Policy in 1996. The district selected by authors is high risk area where chloroquine was recommended in the dose of 25mg/Kg when study was undertaken. However considering that sub therapeutic doses in malaria patients can lead to drug resistance [1] and treatment of non malarial fevers results in unnecessary drug pressure, the policy was revised and full treatment with recommended drug has been advocated for malaria only after diagnosis in the year 2007. Even in cases where diagnosis can not be done and there is high suspicion of malaria, chloroquine is recommended in full dose that too in chloroquine sensitive areas. Further, WHO technical advisory group on malaria has recommended that countries should be discouraged from implementing presumptive, single dose and incomplete treatment with chloroquine [2]. In 2007 Artemisinin based combination therapy (AS-SP) has been implemented in the district. Use of the regimens other than recommended by National Policy (chloroquine in dose of 25mg/Kg and Primaquine) in the present study is an ethical issue. As such there is no statement in the paper regarding ethical clearance

    It is also well known that chloroquine has antipyretic effect [3, 4, 5,] and its use can lead to fever clearance for short duration even in otherwise resistant infections. In addition, in chloroquine resistance studies in India, it has been observed that late treatment failure is common since parasite clearance can be achieved in initial 2-3 days followed by recrudescence [6]. Immunity in population in endemic areas can be the contributing factor and this may have led to decreased morbidity observed by authors. However the late failure invariably results in high gametocyte carriage and thus transmission of selected resistant strains. The lack of significant difference in incidence in high endemic villages and prevalence in low endemic villages has not been explained.

    In the scenario of proposed strategy of early diagnosis by microscopy or rapid diagnostic kit and recommendation of use of artemisinin-based combination therapies (ACTs) , advocating passive distribution of chloroquine through drug distribution centres (DDCs) which are being phased out or upgraded to fever treatment depots (FTDs) will be like going a step backward. The drug pressure created by suggested strategy can make the drug ineffective even for vivax malaria in India.

    References

    1 Frank P. Mockenhaupt, Jurgen May, Yngve Berqvist, Olusegun G. Ademowo, Peter E. Olumese, Adeyinka G. Falusi, Lars Grobterlinden, Christian G. Meyer, and Ulrich Bienzle Concentrations of Chloroquine and Malaria Parasites in Blood in Nigerian children. Antimicrobial Agents and Chemotherapy. 2000, 44: 835-839.

    2 National Drug Policy on Malaria 2007, Directorate of National Vector Borne Disease Control Programme. (www.nvbdcp.gov.in )

    3 D. S. Tarimo, J. N. Minjas and I. C. Bygbjerg Sulfadoxine–pyrimethamine monotherapy in Tanzanian children gives rapid parasite clearance but slow fever clearance that is improved by chloroquine in combination therapy. Tropical Medicine and International Health. 2002, 7: 592–598.

    4 James W. Tracy and Laslie T. Webster, Jr. Drugs used in the chemotherapy of Protozoal Infections In: The Pharmacological Basis of Therapeutics (eds LS Joel G. Hardman and Lee E. Limbird), 10th edn. Mc Graw Hill, 1069-1095

    5 Warrell DA (1993) Treatment and prevention of malaria. In: Bruce–Chwatt’s Essential Malariology (eds HM Gilles & DA Warrell), 3rd edn. Edward Arnold, London, 164–193.

    6 Wijeyaratne Panduka, Chand P.B., Valecha Neena, Shahi B., Adak T., Ansari M.A., Bista M.B., Pandey S., Banerjee S. and Jha S.N. 2005. Therapeutic Efficacy of Anti-Malarial Drugs along the eastern Indo-Nepal Border: a cross-border collaborative study. Trans. Roy. Soc. Trop. Med. Hyg. 99: 423-429.

    Competing interests

    No Competing Interests.

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