The new updates on the WHO recommendations for malaria, established by the WHO Global Malaria Initiative, are provided here as a comprehensive guide for uncomplicated and severe malaria case management.

Reports on malaria

As reported in successive editions of the World Malaria Report, malaria continues to pose excessively high levels of illness and death. Malaria is avoidable and curable and the world's highest priority is to mitigate illness and mortality while maintaining the long-term aim of eradicating the disease.

The Global Technical Strategy for malaria (GTS) establishes an integrated structure for malaria prevention and elimination activities from 2016 to 2030. Both recommendations for managing uncomplicated and serious malaria in all age ranges and conditions, including small children and pregnant mothers, are included in the integrated WHO Guidelines for Malaria.

Treating uncomplicated malaria: Artemisinin-based combination therapy

Treat uncomplicated P. falciparum malaria (2015) using one of the following ACTs to treat adults and children with uncomplicated P. falciparum malaria (except pregnant mothers in their first trimester) (Strong recommendation, high-certainty evidence):

• Artemether + lumefantrine
• Artesunate + amodiaquine
• Artesunate + mefloquine
• Dihydroartemisinin + piperaquine
• Artesunate + sulfadoxine–pyrimethamine (SP).

Remarks: Artesunate pyronaridine is mentioned in the WHO list of pre-qualified malaria medicines, the Model List of Essential Medicines and the Model List of Medicines for Children. The medication has already received a strong scientific opinion from the European Medicines Agency and received a positive recommendation from the WHO Expert Committee on the Quality of Pharmaceutical Drugs.

Countries may consider using this medication in their national care guidelines for malaria treated on the basis of the WHO's position on the use of this medication before a formal recommendation is made in 2021. WHO notes about the use of artesunate-pyronaridine for the therapy of uncomplicated malaria affirms that artesunate pyronaridine can be considered a safe and beneficial ACT for the treatment of uncomplicated malaria in adults and children in all malaria-endemic areas.

Duration of treatment

Treating uncomplicated P. falciparum malaria:

1. Duration of ACT treatment: 3 days of therapy with an artemisinin analogue should be used in ACT regimens.
2. Dosing of ACTS treating uncomplicated P. falciparum malaria (2015): In young children, the dosage guideline for dihydroartemisinin + piperaquine has been revised. Dihydroartemisinin + piperaquine can be given to children weighing less than 25 kg for 3 days at a dose of 2.5 mg/kg bw dihydroartemisinin and 20 mg/kg bw piperaquine.

Treating special risk groups

• Pregnant and lactating women: In the first trimester of pregnancy, treat pregnant women with uncomplicated P. falciparum malaria with quinine + clindamycin for 7 days
• Infants and young children: Treat children weighing less than 5 kg with ACT at the same mg/kg bw targeted dose as children weighing more than 5 kg if they have uncomplicated P. falciparum malaria
• Patients co-infected with HIV: Patients with HIV/AIDS and uncomplicated P. falciparum malaria should prevent artesunate + SP if they are taking co-trimoxazole, and artesunate + amodiaquine if they are taking efavirenz or zidovudine

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

Blood stage infection

1. If malarial parasite species is not recognised with certainty, treat it as uncomplicated.
2. Adults and children with uncomplicated P. vivax, P. ovale, P. malariae, or P. knowlesi malaria should be treated with either ACT (except pregnant women in their first trimester) or chloroquine in places where chloroquine-susceptible infections exist.
3. Adults and children with uncomplicated P.vivax, P. ovale, P. malariae, or P. knowlesi malaria (except pregnant women in their first trimester) should be treated with ACT in places where chloroquine-resistant infections exist.
4. Quinine should be given to pregnant women who have chloroquine-resistant P. vivax malaria in the first trimester.
5. Preventing relapse in P. vivax or P. ovale malaria - The G6PD status of patients can be used to direct primaquine administration for relapse prevention.

Preventing relapse in P. vivax or P. ovale malaria

1. To avoid recurrence treat P. vivax or P. ovale malaria in children and adults (with the exception of pregnant mothers, babies <6 months of age, breast-feeding infants <6 months of age, breast-feeding older infants unless considered to be G6PD deficient and G6PD deficient) with 14-day primaquine in all transmission environments.
2. Consider providing primaquine base at 0.75 mg/kg bw once a week for 8 weeks to people with G6PD deficiency to avoid relapse, with appropriate medical monitoring for possible primaquine-induced haemolysis.
3. Preventing relapse in P. vivax or P. ovale malaria (2015): Where G6PD status is uncertain and G6PD monitoring is not available, prescribing primaquine must be based on a risk-benefit analysis.

Treating severe malaria

Adults and children with significant malaria infection (including children, pregnant women in all trimesters, and lactating women) can receive artesunate intravenously or intramuscularly for at least 24 hours and before they can accept oral medicine; total medication with 3 days of ACT after a patient has had at least 24 hours of parenteral therapy and can tolerate oral therapy.

In small children, the dosage guideline for parenteral artesunate has been revised. To ensure adequate exposure to the medication, children weighing less than 20 kg should receive a higher dosage of artesunate (3 mg/kg bw per dose) than bigger children and adults (2.4 mg/kg bw per dose). If artesunate is unavailable, treat children and adults with severe malaria with artemether rather than quinine.

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.