Ans. c. Primaquine is contraindicated in infants and pregnant women (Ref: Harrison 19/e p1383; Doc/Diagnosis-Treatment-Malaria-2013 .pdf)Primaquine is contraindicated during pregnancy and in lactation unless the infant being breast-fed has a documented normal G6PD level."Primaquine is contraindicated in persons with G6PD deficiency. It is also contraindicated during pregnancy and in lactation unless the infant being breast-fed has a documented normal G6PD level "-- Harrison 19/e p1383."Primaquine is used to prevent relapse but is contraindicated in pregnant women, infants and individuals with G6PD deficiency: ''- style="font-size: 1.04761904761905em; font-family: Times New Roman, Times, serif">. in/Doc/Diagnosis-Treatment-Malaria-2013.pdf"P. falciparum cases should be treated with ACT (Ariesunate 3 days + Sulfadoxine Pyrimethamine 1 day). This is to be accompanied by single dose primaquine preferably on day 2. "-- http:// nvbdcp.gov.in/Doc/Diagnosis-Treatment- Malaria-2013.pdf"In cases where parasitological diagnosis is not possible due to non-availability of either timely microscopy or RdT suspected malaria cases will be treated with full course of chloroquine. till the results of microscopy are received. Once the parasitological diagnosis is available, appropriate treatment as per the species, is to be administered. Presumptive treatment with chloroquine is no more recommended. "-- style="font-size: 1.04761904761905em; font-family: Times New Roman, Times, serif">. PdfTreatment of Uncomplicated MalariaIt is stressed that all fever cases should be suspected of malaria after ruling out other common causes and should be investigated for confirmation of malaria by Microscopy or Rapid Diagnostic Kit (RdK) so as to ensure treatment with full therapeutic dose with appropriate drug to all confirmed cases.The malaria case management is very important for preventive serious cases and death due to malaria. So, the private healthcare providers should also follow the common National Guidelines for treatment of malaria as per the Drug Policy 2013.P. vivax cases should be treated with chloroquine for 3 days & Primaquine for 14 daysQ.Primaquine is used to prevent relapse but is contraindicated in pregnant women, infants and individuals with G6PD deficiencyQ.Note: Patients should be instructed to report back in case of hematuria or high colored urine/ cyanosis or blue coloration of lips and Primaquine should be stopped in such cases. Care should he taken in patients with anemiaQ.P. falciparum cases should be treated with ACT (Artesunate 3 days + Sulfadoxine Pyrimethamine 1 day). This is to be accompanied by single dose primaquine preferably on day 2Q.However, considering the reports of resistance to partner drug SP in North-eastern States, the Technical Advisory Committee has recommended to use the Co-formulated tablet of Artemether (20 mg)--Lumefantrine (120 mg ACT- AL) as per the age-specific dose schedule for the treatment of Pf cases in North Eastern States (not recommended during the first trimester of pregnancy and for children weighing < 5 kg).Production and sale of Artemisinin monotherapy has been banned in IndiaQ.Pregnant women with uncomplicated P. falciparum should be treated as follows:1st Trimester: Quinine2nd & 3rd Trimester: ACTNote: Primaquine is contraindicated in pregnant womanQ.In cases where parasitological diagnosis is not possible due to non-availability of either timely microscopy or RdT, suspected malaria cases will be treated with full course of chloroquine, till the results of microscopy are received. Once the parasitological diagnosis is available, appropriate treatment as per the species, is to be administered.Presumptive treatment with chloroquine is no more recommendedQ.Resistance should be suspected if in spite of full treatment with no history of vomiting, diarrhea, patient does not respond within 72 hours, clinically and parasitologicallySuch cases not responding to ACT, should be treated with oral quinine with Tetracycline/Doxycvcline. These instances should be reported to concerned District Malaria/State Malaria Gfficer/ROHFW for initiation of therapeutic efficacy studies.Treatment of Severe Malaria Severe malaria is an emergency and treatment should be given as per severity & associated complications, which can be best decided by the treating physicians.Before admitting or referring patients, the attending doctor or health worker, whoever is able to do it, should do RdT and take blood smear; give a parenteral dose of artemisinin derivative or quinine in suspected cerebral malaria cases and send case sheet, details of treatment history and blood slide with patient.Parenteral artemisinin derivatives or quinine should be used irrespective of chloroquine resistance status of the area with one of the following options:Chemotherapy of severe and complicated malaria.Initial parenteral treatment for at least 48 hours with one of following four options:Quinine: 20 mg quinine salt/kg body weight on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg 8 hourly; infusion rate should not exceed 5 mg/ kg per hour. Loading dose of 20 mg/kg should not be given, if the patient has already received quinine .Artesunate: 2.4 mg/kg IV or IM given on admission (time = 0), then at 12 h and 24 h, then once a day or Artemether: 3.2 mg/kg IM given on admission then 1.6 mg/kg per day or Arteether: 150 mg daily IM for 3 days in adults only (not recommended for children).Follow-up treatment, when patient can take oral medication following parenteral treatment.Quinine 10 mg/kg three times a day with doxvcycline 100 mg once a day or clindamycin in pregnant women and children under 8 years of age to complete the 7 days of treatment.After parenteral artemisinin therapy, patients will receive a full course of area-specific oral ACT for 3 days.Those patients who received parenteral quinine therapy should receive oral quinine 10 mg/kg body weight three times a day for 7 days (including the days when parenteral quinine was administered) plus doxvcycline 3 mg/kg body weight once a day or clindamycin 10 mg/kg body weight 12-hourly for 7 days (Doxvcycline is contraindicated in pregnant women and children under 8 years of age) or area-specific ACT as described.Note: Pregnant women with severe malaria in any trimester can be treated with artemisinin derivatives, which, in contrast to quinine, do not risk aggravating hypoglycemia. The parenteral treatment should be given for minimum of 48 hours. Once the patient can take oral therapy, give: Quinine 10 mg,'kg three times a day with doxycyciine 100 mg once a day or clindamycin in pregnant women and children under 8 years of age, to complete 7 days of treatment, in patients started on parenteral quinine. Full course of ACT to patients started on artemisinin derivatives.Use of mefloquine should be avoided in cerebral malaria due to neuropsychiatric complications associated with it.