Guideline

WHO Guidelines for malaria, 14 March 2023

Year of Publication

2023

Issuing Institution

WHO

Links

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Recommendations

62 included recommendations

Pyrethroid-chlorfenapyr insecticide-treated nets (ITNs) should be deployed instead of pyrethroid-only Long Lasting Nets (LLNs) 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 insecticide-treated nets (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 insecticide-treated nets (ITNs) can be deployed instead of pyrethroid-only Long Lasting Nets (LLNs) 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 insecticide-treated nets (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

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 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.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Intermittent preventive treatment of malaria in pregnancy (2022) 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 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 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 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

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) prequalified by WHO are recommended for deployment in all malaria-endemic settings

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

WHO suggests deploying pyrethroid-PBO nets instead of pyrethroid-only long-lasting insecticidal nets (LLINs) 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

Insecticide-treated nets: Humanitarian emergency setting (2022): WHO recommends that insecticide-treated nets (ITNs) 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

MDA for burden reduction in emergency settings: 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

MDA to reduce transmission of P. falciparum in very low to low transmission settings. 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

MDA to reduce transmission of P. falciparum in moderate to high transmission settings: 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

MDA to reduce transmission of P. vivax: 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 relapse prevention (MRP) to reduce transmission of P. vivax: 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: 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: 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 malaria-endemic areas: 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 reestablishment of transmission.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Reactive drug administration for reducing malaria transmission: 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: 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. cotravellers 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: 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: Humanitarian emergency setting (2022): WHO suggests deploying indoor residual spraying (IRS) 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

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

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

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

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Pyrethroid-PBO nets instead of pyrethroid-only long-lasting insecticidal nets (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 should 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

Mass drug administration (MDA) for burden reduction: 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

WHO conditionally recommends the use of untreated screening of residential houses for the prevention and control of malaria in children and adults living 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

Maintained

Recommended in favor

Strong

Certainty of evidence

High

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

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

Retired

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

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

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

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

Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.

Status

Updated

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

Children and adults with uncomplicated P. falciparum malaria should be treated 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) Artesunate + sulfadoxine-pyrimethamine and artesunate-pyronaridine are not recommended for use in the first trimester of pregnancy. For details of treatment using ACTs in the first trimester of pregnancy, see 5.2.1.4.1 below.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Artesunate-pyronaridine for uncomplicated malaria: 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

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

Short-course standard dose primaquine treatment: 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

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

Short-course standard high-dose primaquine treatment: To prevent relapse, WHO recommends against an additional treatment option of using primaquine 1.0 mg/kg/ day for seven days to treat P. vivax or P. ovale malaria.

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Pyrethroid-PBO nets instead of pyrethroid-only long-lasting insecticidal nets (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