Guideline

Guidelines for the treatment of malaria

Year of Publication

2015

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

32 included recommendations

Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following artemisinin-based combination therapies (ACT): • artemether + lumefantrine • artesunate + amodiaquine • artesunate + mefloquine • dihydroartemisinin + piperaquine • artesunate + sulfadoxine–pyrimethamine (SP).

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

(Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) Duration of ACT treatment: ACT regimens should provide 3 days treatment with an artemisinin derivative.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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.

Status

Maintained

Recommended in favor

Strong

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. Testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency is not required.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

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

Status

Retired

Recommended in favor

Strong

Infants less than 5kg body weight: 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.

Status

Maintained

Recommended in favor

Strong

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

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

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 glucose-6-phosphate dehydrogenase (G6PD) deficient, and people with G6PD deficiency) with a 14-day course of primaquine in all transmission settings.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In people with glucose-6-phosphate dehydrogenase (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.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In women who are pregnant or breastfeeding, consider weekly chemoprophylaxis with chloroquine until delivery and breastfeeding are completed, then, on the basis of glucose-6-phosphate dehydrogenase (G6PD) status, treat with primaquine to prevent future relapse.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

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 artemisinin-based combination therapy (ACT).

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Revised dose recommendation for parenteral artesunate in young children: 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.

Status

Maintained

Recommended in favor

Strong

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

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Treating cases of suspected severe malaria pending transfer to a higherlevel facility (pre-referral treatment): 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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Treating cases of suspected severe malaria pending transfer to a higherlevel facility (pre-referral treatment): 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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In malaria-endemic areas in Africa, provide intermittent preventive treatment with sulfadoxine-pyrimethamine (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.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

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

Status

Retired

Recommended in favor

Strong

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

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

All cases of suspected malaria should have a parasitological test (microscopy or rapid diagnostic test (RDT)) to confirm the diagnosis. Both microscopy and RDTs should be supported by a quality assurance programme

Status

New

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.

Status

New

Hyperparasitaemia: 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.

Status

New

Treating uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria (Blood stage infection): If the malaria species is not known with certainty, treat as for uncomplicated P. falciparum malaria

Status

New

Preventing relapse in P. vivax or P. ovale malaria: The glucose-6-phosphate dehydrogenase (G6PD) status of patients should be used to guide administration of primaquine for preventing relapse.

Status

New

When glucose-6-phosphate dehydrogenase (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

Status

New

Antimalarial drug quality: 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.

Status

New

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

Status

New

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

Status

New

(Treatment of malaria in pregnancy) Drugs used in Intermitent preventive treatment in pregnancy (IPTp), Seasonal malaria chemoprevention (SMC) and Intermittent Preventive Treatment During Infancy (IPTi) should not be used as a component of firstline treatments in the same country or region.

Status

New

National adaptation and implementation. 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.

Status

New