Guideline

WHO guidelines for malaria, 16 October 2023.

Year of Publication

2023

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

54 included recommendations

Pyrethroid-chlorfenapyr ITNs should be deployed instead of pyrethroid-only LLINs for prevention of malaria in adults and children in areas with pyrethroid resistance.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Pyrethroid-chlorfenapyr ITNs can be deployed instead of pyrethroid-PBO ITNs for prevention of malaria in adults and children in areas with pyrethroid resistance.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Pyrethroid-pyriproxyfen ITNs can be deployed instead of pyrethroid-only LLINs for prevention of malaria in adults and children in areas with pyrethroid resistance.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Pyrethroid-pyriproxyfen ITNs are not recommended for deployment over pyrethroid-PBO ITNs for prevention of malaria in adults and children in areas with pyrethroid resistance.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Moderate

The co-deployment of insecticide treated nets (ITNs) and Indoor residual spraying (IRS) is not recommended for prevention and control of malaria in children and adults in areas with ongoing malaria transmission. Priority should be given to delivering either ITNs or 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

Conditional

Certainty of evidence

Moderate

Travellers with uncomplicated P. falciparum malaria returning to non-endemic settings should be treated with an ACT.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In areas with chloroquine-susceptible infections, adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria should be treated with either an ACT or chloroquine. In areas with chloroquine-resistant infections, adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria should be treated with an ACT.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Preventing relapse in P. vivax or P. ovale malaria (2015): To prevent relapse, children and adults (except pregnant women, infants aged < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient, and people with G6PD deficiency) should be treated with a 14-day course of primaquine in all transmission settings.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

Preventing relapse in people with G6PD deficiency (2015): In people with G6PD deficiency, primaquine base at 0.75 mg/kg bw once a week for 8 weeks can be given to prevent relapse, 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, weekly chemoprophylaxis with chloroquine can be given until delivery and breastfeeding are completed, then, on the basis of G6PD status, primaquine can be given to prevent future relapse.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women) should be treated 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, treatment should be completed with 3 days of an artemisinin-based combination therapy (ACT).

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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. *Not evaluated using the GRADE framework; recommendation based on pharmacokinetic modelling

Status

Updated

Recommended in favor

Strong

Parental alternatives when artesunate is not available (2015): If artesunate is not available, artemether should be used in preference to quinine for treating children and adults with severe malaria.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Where complete treatment of severe malaria is not possible, but injections are available, adults and children should be given a single intramuscular dose of artesunate, and referred to an appropriate facility for further care. Where intramuscular artesunate is not available, intramuscular artemether or, if that is not available, intramuscular quinine should be used.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Where intramuscular injection of artesunate is not available, children < 6 years should be treated with a single rectal dose (10mg/kg bw) of artesunate, and referred immediately to an appropriate facility for further care. Rectal artesunate should not be used in older children and adults.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

In malaria-endemic areas, pregnant women of all gravidities should be given antimalarial medicine at predetermined intervals to reduce disease burden in pregnancy and adverse pregnancy and birth outcomes.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In areas of moderate to high perennial malaria transmission, children belonging to age groups at high risk of severe malaria can be given antimalarial medicines at predefined intervals to reduce disease burden.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

In areas of seasonal malaria transmission, children belonging to age groups at high risk of severe malaria should be given antimalarial medicines during peak malaria transmission seasons to reduce disease burden.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Pyrethroid-only long-lasting insecticidal nets (LLINs) should be deployed for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Pyrethroid-PBO ITNs instead of pyrethroid-only LLINs can be deployed for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission where the principal malaria vector(s) exhibit pyrethroid resistance.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Insecticide-treated nets (ITNs) should be deployed for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission affected by a humanitarian emergency.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

During emergencies or periods of health service disruption, antimalarial medicine can be used for mass drug administration (MDA) in defined geographical areas to provide short-term reductions in the burden of disease caused by P. falciparum.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

In areas with very low to low levels of P. falciparum transmission, antimalarial medicine can be given as chemoprevention through mass drug administration (MDA) to reduce transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

In areas with moderate to high levels of P. falciparum transmission, providing antimalarial medicine through mass drug administration (MDA) to reduce transmission is not recommended.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In areas with P. vivax transmission, antimalarial medicine can be given as chemoprevention through mass drug administration (MDA) to reduce transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Mass treatment with an 8-aminoquinoline medicine alone to reduce the transmission of P. vivax is not recommended.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Mass testing and treatment (MTaT) to reduce the transmission of malaria is not recommended.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Moderate

Targeted drug administration to reduce transmission of malaria (2022): In areas with very low to low transmission or post-elimination settings preventing re-establishment of transmission, antimalarial medicine can be given as chemoprevention to people with increased risk of infection relative to the general population to reduce transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Targeted testing and treatment to reduce transmission of malaria (2022): Testing and treatment of people with an increased risk of infection relative to the general population to reduce the transmission of malaria is not recommended.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Routine malaria testing and treatment of people arriving at points of entry (land, sea or air) to reduce importation is not recommended.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Malaria testing and treatment of organized or identifiable groups arriving or returning from malariaendemic areas (2022) In areas approaching elimination or post-elimination settings preventing re-establishment of transmission, organized or identifiable groups arriving or returning from malaria-endemic areas can be tested and treated soon after entry to reduce importation of malaria. Relatively easy access to these groups within a short time after entry is required for this strategy to be feasible and acceptable. This strategy may be particularly critical to areas in post-elimination that are working to prevent re-establishment of transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Reactive drug administration for reducing malaria transmission (2022): In areas approaching elimination or post-elimination settings preventing re-establishment of transmission, antimalarial medicine can be given as chemoprevention to all people residing with or near a confirmed malaria case and all people who share the same risk of infection (e.g. co-travellers and co-workers) to prevent or reduce malaria transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Reactive case detection and treatment to reduce transmission of malaria (2022): In areas approaching elimination or post-elimination settings preventing re-establishment of transmission, all people residing with or near a confirmed malaria case and all people who share the same risk of infection (e.g. co-travellers and co-workers) can be tested for malaria and treated if positive

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Reactive indoor residual spraying (2022): In areas approaching elimination or post-elimination settings preventing re-establishment of transmission, indoor residual spraying of insecticide can be conducted in in the houses of confirmed cases and neighbours to prevent or reduce transmission of malaria.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Indoor residual spraying (IRS): IRS can be deployed for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission affected by a humanitarian emergency.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Pyrethroid-PBO ITNs instead of pyrethroid-only LLINs can be deployed for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission where the principal malaria vector(s) exhibit pyrethroid resistance.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

School-aged children living in malaria-endemic settings with moderate to high perennial or seasonal transmission can be given a full therapeutic course of antimalarial medicine at predetermined times as chemoprevention to reduce disease burden.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Children admitted to hospital with severe anaemia living in settings with moderate to high malaria transmission can be given a full therapeutic course of an antimalarial medicine at predetermined times following discharge from hospital to reduce re-admission and death.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Antimalarial medicine can be given as chemoprevention through mass drug administration (MDA) in areas of moderate to high transmission of P. falciparum to provide short-term reductions in disease burden.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Screening of residential houses can be used for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

The RTS,S/AS01 malaria vaccine should be used for the prevention of P. falciparum malaria in children living in regions with moderate to high transmission as defined by WHO.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

Insecticides can be regularly applied to water bodies (larviciding) for the prevention and control of malaria in children and adults as a supplementary intervention to insecticide treated nets (ITNs) and Indoor residual spraying (IRS) in areas with ongoing malaria transmission where aquatic habitats are few, fixed and findable

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

The deployment of topical repellents in areas with ongoing malaria transmission is not recommended if the aim is to prevent and control malaria at the community level.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Low

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

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Low

Space spraying is not recommended for the prevention and control of malaria in children and adults in areas with ongoing malaria transmission; insecticide treated nets (ITNs) and Indoor residual spraying (IRS) should be prioritized instead.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Artemisinin-based combination therapy (ACT) regimens should provide 3 days’ treatment with an artemisinin derivative.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In low-transmission areas, a single dose of 0.25 mg/kg bw primaquine should be given with an 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.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Infants weighing < 5 kg with uncomplicated P. falciparum malaria should be treated with an ACT at the same mg/kg bw target dose as for children weighing 5 kg. *Not evaluated using the GRADE framework

Status

Updated

Recommended in favor

Strong

Artemisinin-based combination therapy Treat children and adults with uncomplicated P. falciparum malaria with one of the following ACTs*: • artemether-lumefantrine (AL) • artesunate-amodiaquine (AS+AQ) • artesunate-mefloquine (ASMQ) • dihydroartemisinin-piperaquine (DHAP) • artesunate + sulfadoxine-pyrimethamine (AS+SP) • artesunate-pyronaridine (ASPY) (2022)

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Artesunate-pyronaridine (ASPY) is recommended as an artemisinin-based combination therapy option for the treatment of uncomplicated P. falciparum malaria.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Short-course standard dose primaquine treatment (2022): To prevent relapse, an additional treatment option of using primaquine 0.5 mg/kg/day for seven days is recommended to 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).

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Short-course standard high-dose primaquine treatment (2022): To prevent relapse, an additional treatment option of using primaquine 1.0 mg/kg/day for seven days to treat P. vivax or P. ovale malaria is not recommended.

Status

Updated

Recommended against

Conditional

Certainty of evidence

Very low

Indoor Residual Spraying (IRS) should be deployed for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Treatment in the first trimester of pregnancy: Treat pregnant women with uncomplicated P. falciparum malaria with artemether-lumefantrine during the first trimester

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low