New guidelines for malaria

In Kampala and Moroto, 70% of malaria cases cannot be cured by chloroquine By Charles Wendo THE Ministry of Health has issued new guidelines for malaria treatment amid concerns that the parasites are becoming increasingly resistant to chloroquine. Dr. Frederick Kato, acting head of malaria control says whereas chloroquine still works well in many districts, it fails in some. Surveys have indicated that resistance to chloroquine is commonest in Kampala and Moroto, where chloroquine fails to cure up to 70% of the malaria cases. It is least common in southwestern Uganda where malaria is a relatively new and periodical. Chloroquine has been the first line treatment against malaria, followed by fansidar or other drugs of the same group. The last weapon is quinine. Kato said during a workshop organised by the Health Press Association and Ministry of Health, that in districts where chloroquine seems to be failing, the first line treatment would be a combination of fansidar (or equivalent) and chloroquine. An adult would for instance take three fansidar tablets and four tablets of chloroquine on the first day. This would be followed by four tablets of chloroquine on the second day and two tablets on the third day. Malaria experts discourage the use of fansidar alone because it quickly leads to resistance. In some countries where chloroquine has been dropped as the first line drug in favour of fansidar, malaria quickly developed resistance to fansidar too. "We are trying to reduce the rate at which resistance to fansidar develops. If you use it alone, resistance develops faster. We want to protect fansidar also," says a senior doctor in the malaria control programme. If the chloroquine–fansidar combination fails, the last resort would be quinine. Kato says the recommended method of giving quinine is through drip, but it may also be given through injection into the muscles if it is not possible to set up a drip. "Fortunately, in Uganda quinine resistance has not yet developed. Everybody treated with quinine is expected to recover," he says. In districts where chloroquine still works, it remains the first line treatment. The dose for an adult is four tablets on the first day, four on the second day and three on the third day. If it fails, the second line treatment is fansidar followed by quinine. Kato says the ministry would let district directors of health services decide whether their districts should use chloroquine or the combination of chloroquine and fansidar as the first line treatment. This decision would be based on periodic scientific surveys on resistance to chloroquine. The malaria control programme says drugs like Arthemeter should not be used routinely. They should be reserved for use as the very last resort in case all other drugs fail. "If we get all these drugs on the market and malaria becomes resistant to all of them, where do we turn to? That is what is happening in places like Thailand. Now they have to use combinations of three drugs," says a doctor in the malaria control programme. Kato says that in cases of severe malaria, medical workers should not waste time beginning with chloroquine. They should go straight to quinine by drip. You can tell that malaria is severe if the patient vomits everything, fails to eat, convulses or is in a coma. Under such circumstances, the person should be rushed to a health facility as a matter of urgency. "This business of first line or second line applies only to uncomplicated malaria. Severe malaria is a medical emergency. We do not try one drug then the other," he says. Ends