Diagnosis of malaria
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.
Good practice statement
Treating uncomplicated P. falciparum malaria
Treatment of uncomplicated P. falciparum malaria
Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following recommended artemisinin-based combination therapies (ACT):
artemether + lumefantrine
artesunate + amodiaquine
artesunate + mefloquine
dihydroartemisinin + piperaquine
artesunate + sulfadoxine–pyrimethamine (SP)
Strong recommendation, high-quality evidence
Duration of ACT treatment
ACT regimens should provide 3 days' treatment with an artemisinin derivative.
Strong recommendation, high-quality evidence
Revised dose recommendation for dihydroartemisinin + piperaquine in young children
Children < 25kg treated with dihydroartemisinin + piperaquine should receive a minimum of 2.5 mg/kg body weight (bw) per day of dihydroartemisinin and 20 mg/kg bw per day of piperaquine daily for 3 days.
Strong recommendation based on pharmacokinetic modelling
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.
Strong recommendation, low-quality evidence
Treating uncomplicated P. falciparum malaria in special risk groups
First trimester of pregnancy
Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.
Strong recommendation
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.
Strong recommendation
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.
Good practice statement
Non-immune travellers
Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings with ACT.
Strong recommendation, high-quality evidence
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.
Good practice statement
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.
Good practice statement
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.
Strong recommendation, high-quality evidence
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, high-quality evidence
Treat pregnant women in their first trimester who have chloroquine-resistant P. vivax malaria with quinine.
Strong recommendation, very low-quality evidence
Preventing relapse in P. vivax or P. ovale malaria
The G6PD status of patients should be used to guide administration of primaquine for preventing relapse.
Good practice statement
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.
Strong recommendation, high-quality 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.
Conditional recommendation, very low-quality evidence
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.
Good practice statement
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.
Conditional recommendation, moderate-quality evidence
Treating severe malaria
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, high-quality evidence
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.
Strong recommendation based on pharmacokinetic modelling
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.
Conditional recommendation, low-quality evidence
Treating cases of suspected severe malaria pending transfer to a higher-level facility (pre-referral treatment)
Pre-referral treatment options
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.
Strong recommendation, moderate-quality evidence
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.
Strong recommendation, moderate-quality evidence
Chemoprevention for special risk groups
Intermittent preventive treatment in pregnancy
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.
Strong recommendation, high-quality evidence
Intermittent preventive treatment in infants
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.
Strong recommendation
Seasonal malaria chemoprevention
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.
Strong recommendation, high-quality evidence
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.
Good practice statement
National adaptation and implementation
The choice of ACTs in a country or region should be based on optimal efficacy, safety and adherence.
Good practice statement
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
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.
Good practice statement
