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WHO Guidelines for malaria [Internet]. Geneva: World Health Organization; 2022 Feb 18.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of WHO Guidelines for malaria

WHO Guidelines for malaria [Internet].

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Summary of recommendations

  1. ABBREVIATIONS
  2. EXECUTIVE SUMMARY
  3. INTRODUCTION
  4. PREVENTION
    4.1.

    Vector control

    4.1.1.

    Interventions recommended for large-scale deployment

    Strong recommendation for, High certainty evidence

    Pyrethroid-only nets (2019)

    WHO recommends pyrethroid-only long-lasting insecticidal nets (LLINs) that have been prequalified by WHO for deployment for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission.

    Remark: WHO recommends ITNs that have been prequalified by WHO for use in protecting populations at risk of malaria, including in areas where malaria has been eliminated or transmission interrupted but the risk of reintroduction remains.

    ITNs are most effective where the principal malaria vector(s) bite predominantly at night after people have retired under their nets. ITNs can be used both indoors and outdoors, wherever they can be suitably hung (though hanging nets in direct sunlight should be avoided, as sunlight can affect insecticidal activity).

    Conditional recommendation, Moderate certainty evidence

    Pyrethroid-PBO nets (2019)

    WHO conditionally recommends pyrethroid-PBO nets prequalified by WHO for deployment instead of pyrethroid-only ITNs for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission where the principal malaria vector(s) exhibit pyrethroid resistance that is: a) confirmed, b) of intermediate level, and c) conferred (at least in part) by a monooxygenase-based resistance mechanism, as determined by standard procedures.

    Good practice statement

    Achieving and maintaining optimal coverage with ITNs for malaria prevention and control (2019)

    To achieve and maintain optimal ITN coverage, WHO recommends that countries apply mass free net distribution through campaigns, combined with other locally appropriate delivery mechanisms such as continuous distribution using antenatal care (ANC) clinics and the Expanded Programme on Immunization (EPI).

    Recipients of ITNs should be advised (through appropriate communication strategies) to continue using their nets beyond the three-year expected lifespan of the net, irrespective of the condition and age of the net, until a replacement net is available.

    Good practice statement

    Management of old ITNs (2019)

    WHO recommends that old ITNs should only be collected where there is assurance that: i) communities are not left without nets, i.e., new ITNs are distributed to replace old ones; and ii) there is a suitable and sustainable plan in place for safe disposal of the collected material.

    If ITNs and their packaging (bags and baling materials) are collected, the best option for disposal is high-temperature incineration. They should not be burned in the open air. In the absence of appropriate facilities, they should be buried away from water sources and preferably in non-permeable soil.

    WHO recommends that recipients of ITNs be advised (through appropriate communication strategies) not to dispose of their nets in any water body, as the residual insecticide on the net can be toxic to aquatic organisms (especially fish).

    Strong recommendation for, Low certainty evidence

    Indoor residual spraying (2019)

    WHO recommends IRS using a product prequalified by WHO for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission

    Remark:

    DDT, which has not been prequalified, may be used for IRS if no equally effective and efficient alternative is available, and if it is used in line with the Stockholm Convention on Persistent Organic Pollutants.

    IRS is considered an appropriate intervention where:

    • the majority of the vector population feeds and rests indoors;
    • the vectors are susceptible to the insecticide that is being deployed;
    • people mainly sleep indoors at night;
    • the malaria transmission pattern is such that the population can be protected by one or two rounds of IRS per year;
    • the majority of structures are suitable for spraying; and
    • structures are not scattered over a wide area, resulting in high transportation and other logistical costs.

    Good practice statement

    Access to ITNs or IRS at optimal coverage levels (2019)

    WHO recommends ensuring access to effective vector control using ITNs or IRS at optimal coverage levels for all populations at risk of malaria in most epidemiological and ecological settings.

    4.1.2.

    Combining ITNs and IRS

    Conditional recommendation against, Moderate certainty evidence

    Prioritize optimal coverage with either ITNs or IRS over combination (2019)

    WHO recommends against combining ITNs and IRS and that priority be given to delivering either ITNs or IRS at optimal coverage and to a high standard, rather than introducing the second intervention as a means to compensate for deficiencies in the implementation of the first intervention.

    Remark:

    In settings where optimal ITN coverage, as specified in the strategic plan, has been achieved and where ITNs remain effective, additionally implementing IRS may have limited utility in reducing malaria morbidity and mortality. Given the resource constraints across malaria-endemic countries, it is recommended that effort be focused on good-quality implementation of either ITNs or IRS, rather than deploying both in the same area. However, the combination of these interventions may be considered for resistance prevention, mitigation or management should sufficient resources be available.

    Good practice statement

    No scale-back in areas with ongoing local malaria transmission (2019)

    In areas with ongoing local malaria transmission (irrespective of both the pre-intervention and current level of transmission), WHO recommends that vector control interventions should not be scaled back. Ensuring access to effective malaria vector control at optimal levels for all inhabitants of such areas should be pursued and maintained.

    4.1.3.

    Supplementary interventions

    Conditional recommendation, Low certainty evidence

    Larviciding (2019)

    WHO conditionally recommends the regular application of biological or chemical insecticides to water bodies (larviciding) for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission as a supplementary intervention in areas where optimal coverage with ITNs or IRS has been achieved, where aquatic habitats are few, fixed and findable, and where its application is both feasible and cost-effective.

    Remark:

    Since larviciding only reduces vector density, it does not have the same potential for health impact as ITNs and IRS – both of which reduce vector longevity and provide protection from biting vectors. As a result, larviciding should never be seen as a substitute for ITNs or IRS in areas with significant malaria risk but represents a potential supplementary strategy for malaria control. Larviciding will generally be most effective in areas where larval habitats are few, fixed and findable, and likely less feasible in areas where the aquatic habitats are abundant, scattered and variable.

    The following settings are potentially the most suitable for larviciding as a supplementary measure implemented alongside ITNs or IRS:

    • urban areas: where breeding sites are relatively few, fixed and findable in relation to houses (which are targeted for ITNs or IRS);
    • arid regions: where larval habitats may be few and fixed throughout much of the year.

    Larval habitat modification and/or larval habitat manipulation (2021)

    No recommendation can be made because the evidence on the effectiveness of a specific larval habitat modification and/or larval habitat manipulation intervention for the prevention and control of malaria was deemed to be insufficient.

    Larvivorous fish (2019)

    No recommendation can be made because no evidence on the effectiveness of larvivorous fish for the prevention and control of malaria was identified.

    Conditional recommendation against, Low certainty evidence

    Topical repellents (2019)

    WHO conditionally recommends against the deployment of topical repellents for the prevention and control of malaria at the community level in areas with ongoing malaria transmission.

    Remark:

    Further work is required to investigate the potential public health value of topical repellents to separate out potential effects at the individual and/or community level. Analysis conducted to date indicates that no significant impact on malaria can be achieved when the intervention is deployed at community-level due to the high level of individual compliance needed.

    Conditional recommendation against, Low certainty evidence

    Insecticide-treated clothing (2019)

    WHO conditionally recommends against deployment of insecticide-treated clothing for the prevention and control of malaria at the community level in areas with ongoing malaria transmission; however, insecticide-treated clothing may be beneficial as an intervention to provide personal protection against malaria in specific population groups.

    Remark: In the absence of insecticide-treated nets, there is some evidence that insecticide-treated clothing may reduce the risk of malaria infection in specific populations such as refugees and military; it is presently unclear if the results are applicable to the general population.

    Spatial/Airborne repellents (2019)

    No recommendation can be made because the evidence on the effectiveness of spatial/airborne repellents for the prevention and control of malaria was deemed to be insufficient.

    Conditional recommendation against, Very low certainty evidence

    Space spraying (2019)

    WHO conditionally recommends against using space spraying for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission; IRS or ITNs should be prioritized instead.

    Conditional recommendation, Low certainty evidence Image ch1if1.jpg

    House screening (2021)

    WHO conditionally recommends the use of untreated screening of residential houses for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission.

    Remark:

    This recommendation addresses the use of untreated screening of windows, ceilings, doors and/or eave spaces, and does not cover other ways of blocking entry points in houses.

    4.1.4.

    Other considerations for vector control

    4.1.4.1.

    Special situations

    4.1.4.2.

    Implementation challenges

    4.1.4.3.

    Monitoring and evaluation of vector control

    4.1.5.

    Research needs

    4.2.

    Preventive chemotherapies & Mass drug administration

    4.2.1.

    Intermittent preventive treatment of malaria in pregnancy (IPTp)

    Strong recommendation for, High certainty evidence

    In malaria-endemic areas in Africa, provide intermittent preventive treatment with SP to all women in their first or second pregnancy (SP-IPTp) as part of antenatal care. Dosing should start in the second trimester and doses should be given at least 1 month apart, with the objective of ensuring that at least three doses are received.

    4.2.2.

    Intermittent preventive treatment of malaria in infants (IPTi)

    Strong recommendation for

    In areas of moderate-to-high malaria transmission of Africa, where SP is still effective, provide intermittent preventive treatment with SP to infants (< 12 months of age) (SP-IPTi) at the time of the second and third rounds of vaccination against diphtheria, tetanus and pertussis (DTP) and vaccination against measles.

    *unGRADEd recommendation, anticipated to be updated in 2022

    4.2.3.

    Seasonal malaria chemoprevention (SMC)

    Strong recommendation for, High certainty evidence

    In areas with highly seasonal malaria transmission in the Sahel subregion of Africa, provide seasonal malaria chemoprevention (SMC) with monthly amodiaquine + SP for all children aged < 6 years during each transmission season.

    4.3.

    Vaccine

    Strong recommendation for, High certainty evidence Image ch1if1.jpg

    The RTS,S/AS01 malaria vaccine should be used for the prevention of P. falciparum malaria in children living in regions with moderate to high transmission as defined by WHO.

    Remark:

    • The RTS,S/AS01 malaria vaccine should be provided in a four-dose schedule in children from 5 months of age.
    • Countries may consider providing the RTS,S/AS01 vaccine seasonally, with a five-dose strategy, in areas with highly seasonal malaria or with perennial malaria transmission with seasonal peaks.
    • Countries that choose to introduce the vaccine in a five-dose seasonal strategy are encouraged to document their experiences, including adverse events following immunization.
    • RTS,S/AS01 malaria vaccine should be provided as part of a comprehensive malaria control strategy.

  5. CASE MANAGEMENT
    5.1.

    Diagnosing malaria (2015)

    Good practice statement

    All cases of suspected malaria should have a parasitological test (microscopy or RDT) to confirm the diagnosis.

    Both microscopy and RDTs should be supported by a quality assurance programme.

    5.2.

    Treating uncomplicated malaria

    5.2.1.

    Artemisinin-based combination therapy

    Strong recommendation for, High certainty evidence

    Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following ACTs:

    • artemether + lumefantrine
    • artesunate + amodiaquine
    • artesunate + mefloquine
    • dihydroartemisinin + piperaquine
    • artesunate + sulfadoxine–pyrimethamine (SP)
    • artesunate + pyronaridine (currently unGRADEd, anticipated to be updated in 2022)

    Remark:

    Artesunate pyronaridine is included in the WHO list of prequalified medicines for malaria, the Model List of Essential Medicines and the Model List of Medicines for Children. The drug has also received a positive scientific opinion from the European Medicines Agency and undergone a positive review by the WHO Advisory Committee on Safety of Medicinal Products. Countries can consider including this medicine in their national treatment guidelines for the treatment of malaria based on WHO’s position on the use of this drug pending the formal recommendation anticipated in 2021. WHO’s position was published in the information note The use of artesunate-pyronaridine for the treatment of uncomplicated malaria (122) which clarifies that artesunate pyronaridine can be considered a safe and efficacious ACT for the treatment of uncomplicated malaria in adults and children weighing 5 kg and over in all malaria-endemic areas.

    5.2.2.

    Duration of treatment

    Strong recommendation for, High certainty evidence

    Treating uncomplicated P. falciparum malaria (2015)

    Duration of ACT treatment: ACT regimens should provide 3 days’ treatment with an artemisinin derivative.

    5.2.3.

    Dosing of ACTS

    Strong recommendation for

    Revised dose recommendation for dihydroartemisinin + piperaquine in young children: Children weighing <25kg treated with dihydroartemisinin + piperaquine should receive a minimum of 2.5 mg/kg bw per day of dihydroartemisinin and 20 mg/ kg bw per day of piperaquine daily for 3 days.

    *unGRADEd recommendation, anticipated to be updated in 2022

    5.2.4.

    Recurrent falciparum malaria

    5.2.5.

    Reducing the transmissibility of treated P. falciparum infections in areas of low-intensity transmission

    Strong recommendation for, Low certainty evidence

    Reducing the transmissibility of treated P. falciparum infections: In low-transmission areas, give a single dose of 0.25 mg/kg bw primaquine with ACT to patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months) to reduce transmission. G6PD testing is not required.

    5.3.

    Treating special risk groups

    5.3.1.

    Pregnant and lactating women

    Strong recommendation for

    Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.

    *unGRADEd recommendation, anticipated to be updated in 2022

    5.3.2.

    Young children and infants

    Strong recommendation for

    Infants less than 5kg body weight (2015)

    Treat infants weighing < 5 kg with uncomplicated P. falciparum malaria with ACT at the same mg/kg bw target dose as for children weighing 5 kg.

    *unGRADEd recommendation, anticipated to be updated in 2022

    5.3.3.

    Patients co-infected with HIV

    Good practice statement

    Patients co-infected with HIV (2015)

    Patients co-infected with HIV: In people who have HIV/AIDS and uncomplicated P. falciparum malaria, avoid artesunate + SP if they are being treated with co-trimoxazole, and avoid artesunate + amodiaquine if they are being treated with efavirenz or zidovudine.

    5.3.4.

    Non-immune travellers

    Strong recommendation for, High certainty evidence

    Non-immune travellers (2015)

    Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings with ACT.

    5.3.5.

    Uncomplicated hyperparasitaemia

    Good practice statement

    Hyperparasitaemia (2015)

    People with P. falciparum hyperparasitaemia are at increased risk for treatment failure, severe malaria and death and should be closely monitored, in addition to receiving ACT.

    5.4.

    Treating uncomplicated malaria caused by P. vivax, P. ovale, P. malariae or P. knowlesi

    Good practice statement

    Blood stage infection (2015)

    If the malaria species is not known with certainty, treat as for uncomplicated.

    Strong recommendation for, High certainty evidence

    In areas with chloroquine-susceptible infections, treat adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria with either ACT (except pregnant women in their first trimester) or chloroquine.

    In areas with chloroquine-resistant infections, treat adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria (except pregnant women in their first trimester) with ACT.

    Strong recommendation for, Very low certainty evidence

    Blood stage infection (2015)

    Treat pregnant women in their first trimester who have chloroquine-resistant P. vivax malaria with quinine.

    Good practice statement

    The G6PD status of patients should be used to guide administration of primaquine for preventing relapse.

    Strong recommendation for, High certainty evidence

    To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants aged < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient, and people with G6PD deficiency) with a 14-day course of primaquine in all transmission settings.

    Conditional recommendation, Very low certainty evidence

    In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced haemolysis.

    Good practice statement

    Preventing relapse in P. vivax or P. ovale malaria (2015)

    When G6PD status is unknown and G6PD testing is not available, a decision to prescribe primaquine must be based on an assessment of the risks and benefits of adding primaquine.

    Conditional recommendation, Moderate certainty evidence

    Pregnant and breastfeeding women: In women who are pregnant or breastfeeding, consider weekly chemoprophylaxis with chloroquine until delivery and breastfeeding are completed, then, on the basis of G6PD status, treat with primaquine to prevent future relapse.

    5.5.

    Treating severe malaria

    5.5.1.

    Artesunate

    Strong recommendation for, High certainty evidence

    Treat adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women) with intravenous or intramuscular artesunate for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oral therapy, complete treatment with 3 days of ACT.

    Strong recommendation for

    Children weighing < 20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug.

    *unGRADEd recommendation based on pharmacokinetic modelling, anticipated to be updated in 2022

    5.5.2.

    Parenteral alternatives when artesunate is not available

    Conditional recommendation, Low certainty evidence

    If artesunate is not available, use artemether in preference to quinine for treating children and adults with severe malaria.

    5.5.3.

    Pre-referral treatment options

    Strong recommendation for, Moderate certainty evidence

    Where complete treatment of severe malaria is not possible, but injections are available, give adults and children a single intramuscular dose of artesunate, and refer to an appropriate facility for further care. Where intramuscular artesunate is not available use intramuscular artemether or, if that is not available, use intramuscular quinine.

    Where intramuscular injection of artesunate is not available, treat children < 6 years with a single rectal dose (10mg/kg bw) of artesunate, and refer immediately to an appropriate facility for further care. Do not use rectal artesunate in older children and adults.

    5.6.

    Other considerations in treating malaria

    5.6.1.

    Management of malaria cases in special situations

    5.6.2.

    Quality of antimalarial drugs

    Good practice statement

    Antimalarial drug quality (2015)

    National drug and regulatory authorities should ensure that the antimalarial medicines provided in both the public and the private sectors are of acceptable quality, through regulation, inspection and law enforcement.

    5.6.3.

    Monitoring efficacy and safety of antimalarial drugs and resistance

    Good practice statement

    All malaria programmes should regularly monitor the therapeutic efficacy of antimalarial drugs using the standard WHO protocols.

    5.7.

    National adaptation and implementation

    Good practice statement

    The choice of ACTs in a country or region should be based on optimal efficacy, safety and adherence.

    Good practice statement

    National adaptation and implementation (2015)

    Drugs used in IPTp, SMC and IPTi should not be used as a component of first- line treatments in the same country or region.

    Good practice statement

    National adaptation and implementation (2015)

    When possible, use:

    • fixed-dose combinations rather than co-blistered or loose, single-agent formulations; and
    • for young children and infants, paediatric formulations, with a preference for solid formulations (e.g. dispersible tablets) rather than liquid formulations.

  6. ELIMINATION
  7. SURVEILLANCE
  8. METHODS
  9. GLOSSARY
  10. CONTRIBUTORS AND INTERESTS
    10.1.

    Guidelines for malaria vector control

    10.2.

    Malaria vaccine recommendation

    10.3.

    Guidelines for the treatment of malaria

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