Guideline

WHO guidelines for malaria, 16 February 2021.

Year of Publication

2021

Issuing Institution

WHO

Links

WHO IRIS,WHO IRIS

Recommendations

52 included recommendations

Pyrethroid-only long-lasting insecticidal nets (LLINs) prequalified by WHO are recommended for deployment in all malaria-endemic settings

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Pyrethroid-PBO nets prequalified by WHO are conditionally recommended for deployment instead of pyrethroidonly insecticide-treated nets (ITNs) 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.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Indoor residual spraying (IRS): IRS deploying a product prequalified by WHO is recommended in most malaria-endemic settings. DDT has not been prequalified; it 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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Priority should be given to delivering either insecticide-treated net (ITNs) or Indoor residual spraying (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

Status

Maintained

Recommended against

Strong

Certainty of evidence

Moderate

The regular application of biological or chemical insecticides to water bodies (larviciding) is recommended for malaria prevention and control as a supplementary intervention in areas where optimal coverage withinsecticide-treated net (ITNs) or indoor residual spraying (IRS) has been achieved, where aquatic habitats are few, fixed and findable, and where its application is both feasible and cost-effective.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

No recommendation can be made because evidence on the effectiveness (or harms) of larvivorous fish was not identified

Status

Updated

Insufficient data to recommend

Deployment of topical repellents for malaria prevention at the community level is not recommended; however, topical repellents may be beneficial as an intervention to provide personal protection against mosquito bites.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Low

Deployment of insecticide-treated clothing for malaria prevention at the community level is not recommended; however, insecticide-treated clothing may be beneficial as an intervention to provide protection against malaria in specific population groups. Deployment of insecticide-treated clothing for malaria prevention at the community level is not recommended; however, insecticide-treated clothing may be beneficial as an intervention to provide protection against malaria in specific population groups.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Low

No recommendation on the deployment of spatial/airborne repellents in the prevention and control of malaria can be made until ongoing studies assessing malaria epidemiological outcomes have been completed.

Status

Updated

Space spraying should not be undertaken for malaria control, and indoor residual spraying (IRS) or insecticide-treated nets (ITNs) should be prioritized instead

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

In malaria-endemic areas in Africa, provide intermittent preventive treatment (IPT) 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

Maintained

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-IPTi) at the time of the second and third rounds of vaccination against diphtheria, tetanus and pertussis (DTP) and vaccination against measles.

Status

Updated

Recommended in favor

Strong

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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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)

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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

Maintained

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 artemisinin-based combination therapy (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 artemisinin-based combination therapy (ACT) (except pregnant women in their first trimester) or chloroquine.

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 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

To achieve and maintain optimal insecticide treated nets (ITN) coverage, countries should apply a combination of mass free net distribution through campaigns and continuous distribution through multiple channels such as through antenatal care clinics(ANC) and the expanded programme on immunization (EPI).

Status

Updated

Recipients of insecticide-treated net (ITNs) should be advised (through appropriate communication strategies) to continue using their nets beyond the 3-year expected lifespan of the net, irrespective of the condition and age of the net, until areplacement net is available

Status

Updated

Old insecticide-treated net (ITNs) should only be collected where there is assurance that: i) communities are not left uncovered and ii) there is a suitable and sustainable plan in place for safe disposal of the collected material

Status

Updated

If insecticide-treated net (ITNs) and their packaging (bags and baling materials) are collected, the best option for disposal is hightemperature 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.

Status

Updated

Recipients of insecticide-treated net (ITNs) should 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).

Status

Updated

Universal coverage with effective vector control using a core intervention insecticide treated nets (ITNs) or Indoor residual spraying (IRS) is recommended for all populations at risk of malaria in most epidemiological and ecological settings. The population at risk of malaria may increase or decrease as a result of changes in malariogenic potential of a given geographical area.

Status

Updated

Once optimal coverage with either insecticide-treated nets (ITNs) or indoor residual spraying (IRS) has been achieved, programmes may consider deploying the other intervention as an approach to prevent, manage and mitigate insecticide resistance. The ITN and IRS products selected for co-deployment must not contain the same insecticide class(es). For instance, IRS with a pyrethroid should not be deployed in the same households or areas as ITNs. The decision to deploy a second vector control intervention should only be taken after conducting a prioritization analysis across malaria interventions, not just vector control, to ensure maximum impact of any additional resources.

Status

Updated

Once high coverage with a core intervention has been achieved, recommended supplementary interventions with proven public health value may be deployed in specific settings and circumstances. The decision to deploy a supplementary vector control intervention should only be taken after conducting a prioritization analysis across malaria interventions, not just vector control, to ensure maximum impact of any additional resources.

Status

Updated

In areas with ongoing local malaria transmission (irrespective of both the preintervention and current level of transmission), 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.

Status

Updated

If areas where transmission has been interrupted are identified, the decision to scale-back of vector control should be based on a detailed analysis that includes assessment of the receptivity and vulnerability of the area, as well as an assessment of the active disease surveillance system, and capacity for case management and vector control response.

Status

Updated

(Diagnosis of malaria) 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

Updated

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

Updated

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 artemisinin-based combination therapy (ACT).

Status

Updated

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

Updated

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

Updated

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

Updated

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

Updated

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

Status

Updated

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

Status

Updated

(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 first- line treatments in the same country or region.

Status

Updated

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

Updated