This World Malaria Day, here is an article that highlights the latest WHO guidelines for the prevention, diagnosis and treatment of malaria.

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What do the latest statistics show?

Malaria continues to cause unacceptably high levels of disease and death. A recent survey in 2020 reported 241 million cases of malaria and 6,27,000 deaths globally. The Global Technical Strategy states that it is essential for malaria programmes to 'ensure access to malaria prevention, diagnosis and treatment as part of Universal Health Coverage.'

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Prevention of malaria as per WHO guidelines 2022

1. Interventions recommended for large-scale deployment

• Pyrethroid-only long-lasting insecticidal nets
• Pyrethroid-PBO nets
• Insecticide-treated nets (ITN)
• Indoor residual spraying (IRS)

2. Co-deploying ITNs and IRS

3. Supplementary interventions

• Larviciding
• Topical repellents
• Insecticide-treated clothing
• Spatial/Airborne repellents
• Space spraying
• House screening

4. Further Research needs

1. High research standards around prevention and management should be employed in conducting, analysing and reporting studies, ensuring that studies are adequately powered and appropriate randomization methods and statistical analyses are used. 
2. WHO requires studies to be conducted in compliance with international ethical standards and good clinical and laboratory practices.

Preventive chemotherapies & mass drug administration

1. Intermittent preventive treatment of malaria in pregnancy (IPTp)

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

2. Intermittent preventive treatment of malaria in infants (IPTi)

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

3. Seasonal malaria chemoprevention (SMC)

1. In areas with highly seasonal malaria transmission, provide Seasonal Malaria Chemoprevention (SMC)
2. Monthly amodiaquine + SP for all children aged <6 years during each transmission season.

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Case management

1. Diagnosing malaria (2015)- All cases of suspected malaria should have a parasitological test (microscopy or RDT) to confirm the diagnosis.

2. Treating uncomplicated malaria

1.  Artemisinin-based Combination Therapy (ACT)- 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

2. Duration of treatment- Treating uncomplicated P. falciparum malaria, the duration of ACT treatment should provide 3 days of treatment with an artemisinin derivative.
3. Dosing of ACTS- 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.
4. Recurrent falciparum malaria
   1. Recurrence of P. falciparum malaria can result from re-infection or recrudescence (treatment failure).
   2. Treatment failure may result from drug resistance or inadequate exposure to the drug due to sub-optimal dosing, poor adherence, vomiting, unusual pharmacokinetics in an individual, or substandard medicines.
   3. It is important to determine from the patient’s history whether he or she vomited the previous treatment or did not complete a full course of treatment.
   4. The recommended second-line treatment is an alternative ACT known to be effective in the region.
5. Reducing the transmissibility of treated P. falciparum infections in areas of low-intensity transmission- 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.
6. Treating special risk groups
   1. Pregnant and lactating women- Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.
   2. Young children and infants- 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.
7. 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.
8. Non-immune travellers- Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings with ACT.
9. Uncomplicated hyperparasitemia- People with P. falciparum Hyperparasitemia are at increased risk for treatment failure, severe malaria and death and should be closely monitored, in addition to receiving ACT.

3. Treating severe malaria

1. Artesunate

• 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 hrs or until they can tolerate oral medication.
• Once a patient has received at least 24 hours of parenteral therapy and can tolerate oral therapy, complete treatment with 3 days of ACT.
• 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.

2. Parenteral alternatives when Artesunate is not available- Use artemether in preference to quinine for treating children and adults with severe malaria.
3. Pre-referral treatment options- Where complete treatment of severe malaria is not possible, but injections are available, give adults and children a single i.m dose of Artesunate, and refer them to an appropriate facility for further care.

If i.m Artesunate is not available:

1. Use i.m Artemether or Quinine.
2. Treat children <6 years with a single rectal dose (10mg/kg BW) of Artesunate, and refer them immediately to an appropriate facility for further care. Do not use rectal artesunate in older children and adults.

4. Other considerations in treating malaria

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

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.