Times of India
12 August 2010
By Prithvijit Mitra
Kolkata, India

Even as the number of malaria patients keeps climbing in Kolkata, the civic authorities have alleged that most leading private hospitals and clinics are not following treatment norms prescribed by WHO. Instead of a combination therapy – which involves supplementing treatment with a second–line drug to rule out relapse and resistance – patients are being administered a single drug, which is helping to transmit the parasite, it has been alleged.

Some private hospitals denied the charge and passed the blame on to KMC saying that they, too, were guilty of bypassing the malaria treatment regimen. Around 2000 people are now suffering from malaria in the city; there have been two deaths so far. Around 50% of the patients in the malaria–prone areas of the city are believed to have developed resistance to first–line drugs.

"It is imperative, under the norms, to combine artemisinin group of drugs with sulphadoxin pyrimethamine or lumesanthrine to treat falciparum (malignant) malaria patients. Alternatively, quinine could be used in combination with toxycycline or clindamycin. We have come across scores of patients at our clinics who were prescribed artemisinin or quinine in isolation at private hospitals and clinics. Many of these patients have suffered a relapse and could develop resistance in future.

More importantly, this violates the malaria treatment norm," said Tomonash Bhattacharya, civic medical officer and tropical medicine expert.

A combined therapy helps to prevent resistance and roots out parasites from the blood effectively.
"Since they act at two different stages of the parasitic cycle, the chances of the parasite remaining dormant are almost nil. Single–drug therapy often seems to have cured malaria, but the parasite survives and turns active after a while. Scores of patients have suffered a relapse this season. It is also likely to have added to the number of drugresistant patients," added Bhattacharya.

A prescription issued by a leading private hospital, in possession of TOI, prescribes quinine without a combination drug. The patient, suffering from falciparum malaria, had a relapse and sought treatment from a private practitioner. Another prescription recommends primaquin in a low dose, which could help transmission, say experts.

"This is a major lapse in a situation like this. Unless you prescribe a loading dose which effectively kills the gametocyte (the transmitting form) of the falciparum, the patient might turn a carrier. He will have no symptoms of malaria but go on transmitting the disease so long as the gametocyte survives in the bloodstream. We have thousands of such silent carriers in Kolkata now," said Debashish Basu, an expert in preventive medicine.

Even while admitting that single–drug therapy was being used, private hospitals pointed out that combination drugs were often not available. It was primarily KMC’s responsibility to arrange for treatment of malaria patients and ensure that the drug regime was adhered to.

"KMC clinics, too, are not following norms. They rarely take a G6PD test, which is mandatory before primaquin is prescribed to malaria vivax patients. The civic authorities have failed to either prevent breeding of mosquito or provide treatment to patients. They have even failed to launch an effective malaria awareness campaign," said Syamasis Bandopadhyay, internal medicine expert at Apollo Gleagles Hospital.