Management of Malaria in India
For uncomplicated Plasmodium falciparum malaria in India, artemisinin-based combination therapy (ACT) is the first-line treatment, with artemether-lumefantrine (AL) being the recommended regimen, especially in northeastern states where resistance to artesunate-sulfadoxine/pyrimethamine (AS+SP) has emerged. 1, 2
Classification and Initial Assessment
Uncomplicated Malaria
- Symptoms: Fever, headache, myalgia without signs of severe disease
- Parasitemia: <1% in non-immune individuals
- Patient can take oral medication
Severe Malaria (Medical Emergency)
- Any of the following: impaired consciousness, seizures, respiratory distress, shock, jaundice, severe anemia, acidosis, hypoglycemia, hyperparasitemia (>4%), or renal failure 3
- Parasitemia >4% is a key criterion for ICU admission in non-immune populations 3
Treatment Algorithm
1. Uncomplicated P. falciparum Malaria
First-line treatment:
- Artemether-Lumefantrine (AL) 4, 1, 2
- Dosing: For adults >35 kg: 4 tablets at 0,8,24,36,48, and 60 hours (total 24 tablets over 3 days)
- Must be taken with fatty meal or drink
- Monitor for adverse effects: headache, vertigo, digestive disorders, QTc prolongation
Alternative first-line (in regions without AS+SP resistance):
Second-line options:
Dihydroartemisinin-Piperaquine 4
- For adults 36-75 kg: 3 tablets daily for 3 days
- For adults >75 kg: 4 tablets daily for 3 days
- Must be taken in fasting condition
- Monitor for QTc prolongation
Atovaquone-Proguanil 4
- Adults >40 kg: 4 tablets daily for 3 days
- Must be taken with fatty meal
- Relatively slow-acting regimen
2. Uncomplicated P. vivax Malaria
- Chloroquine 7
- Initial dose: 600 mg base, followed by 300 mg base after 6-8 hours
- Then 300 mg base on each of two consecutive days (total 1.5 g base)
- PLUS
- Primaquine for radical cure (to eliminate liver hypnozoites) 4
3. Severe Malaria (Any Species)
First-line treatment:
- IV Artesunate 3
- Dosing: 2.4 mg/kg at 0,12, and 24 hours, then daily
- Continue until parasitemia <1% and patient can take oral medication
- Then complete treatment with full course of oral ACT
If IV artesunate unavailable:
- IV Quinine 4, 8
- Loading dose: 20 mg salt/kg (over 4 hours)
- Maintenance: 10 mg salt/kg every 8 hours (over 4 hours)
- Monitor for cinchonism, hypoglycemia, and QT prolongation
- Switch to oral therapy when patient improves
Monitoring and Follow-up
For Uncomplicated Malaria
- Clinical assessment daily until fever resolves
- Parasitological assessment on day 3 (should show significant reduction)
- Follow-up on days 7,14, and 28 to ensure complete cure
For Severe Malaria
- Check parasitemia every 12 hours until <1%, then every 24 hours until negative 3
- Monitor vital signs, consciousness level, and urine output hourly
- Daily monitoring of full blood count, renal and liver function, glucose, and electrolytes 3
- Watch for complications: seizures, respiratory distress, worsening acidosis
Special Considerations
Pregnant Women
- ACTs are safe in second and third trimesters
- For first trimester, quinine plus clindamycin is preferred if available
Children
- Use weight-adjusted dosing for all medications
- For severe malaria, manage seizures according to standard protocols 4
- Monitor glucose levels closely as hypoglycemia is common
Drug Resistance Concerns
- Resistance to AS+SP has been documented in northeastern states of India 1, 2
- Regular monitoring of ACT efficacy is essential in view of malaria elimination initiatives 1
- Molecular markers (Pfdhfr, Pfdhps, Pfk13) should be monitored for emerging resistance 2, 5
Supportive Care
- Restrictive fluid management to avoid pulmonary or cerebral edema 3
- Correct hypoglycemia with 5 mL/kg of 10% dextrose if needed 3
- Monitor and correct electrolyte imbalances, particularly potassium 3
- Start antibiotics only if bacterial co-infection is suspected 3
The management of malaria in India requires prompt diagnosis and appropriate treatment based on the species identified and severity of infection. With increasing concerns about drug resistance, particularly in northeastern states, regular monitoring of therapeutic efficacy and adherence to national treatment guidelines are essential for successful malaria control and eventual elimination.