Overview of malaria treatment

Last update: 18 January 2018

Malaria is a preventable and treatable disease. The primary objective of treatment is to ensure complete cure, that is the rapid and full elimination of the Plasmodium parasite from the patient’s blood, in order to prevent progression of uncomplicated malaria to severe disease or death, and to prevent chronic infection that leads to malaria-related anaemia.

From a public health perspective, the goal of treatment is to reduce transmission of the infection to others, by reducing the infectious reservoir, and to prevent the emergence and spread of resistance to antimalarial medicines.

Importance of diagnostic testing

Patients with suspected malaria should have parasitological confirmation of diagnosis with either microscopy or rapid diagnostic test (RDT) before antimalarial treatment is started. Treatment based on clinical grounds should only be given if diagnostic testing is not immediately accessible within 2 hours of patients presenting for treatment. Prompt treatment – within 24 hours of fever onset – with an effective and safe antimalarial is necessary to effect a cure and prevent life-threatening complications.

Treatment of uncomplicated malaria

Treatment of P. falciparum infections

WHO recommends artemisinin-based combination therapies (ACTs) for the treatment of uncomplicated malaria caused by the P. falciparum parasite. By combining 2 active ingredients with different mechanisms of action, ACTs are the most effective antimalarial medicines available today. WHO currently recommends 5 ACTs for use against P. falciparum malaria. The choice of ACT should be based on the results of therapeutic efficacy studies against local strains of P. falciparum malaria.

ACTs are the mainstay of recommended treatment for P. falciparum malaria and, as no alternative to artemisinin derivatives is expected to enter the market for several years, their efficacy must be preserved. WHO recommends that national malaria control programmes regularly monitor the efficacy of antimalarial medicines in use to ensure that the chosen treatments remain efficacious.

In low transmission areas, a single low dose of primaquine should be added to the antimalarial treatment in order to reduce transmission of the infection. Testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency is not required, as a single low dose of primaquine is both effective in blocking transmission and unlikely to cause serious toxicity in individuals with any of the G6PD-deficiency variants.

Oral monotherapy and artemisinin resistance

Artemisinin and its derivatives must not be used as oral monotherapy, as this promotes the development of artemisinin resistance. Moreover, fixed-dose formulations (combining 2 different active ingredients co-formulated in 1 tablet) are strongly preferred and recommended over co-blistered, co-packaged or loose tablet combinations, since they facilitate adherence to treatment and reduce the potential use of the individual components as monotherapy.

Treatment of P. vivax infections

P. vivax infections should be treated with an ACT or chloroquine in areas without chloroquine-resistant P. vivax. In areas where chloroquine-resistant P. vivax has been identified, infections should be treated with an ACT, preferably one in which the partner medicine has a long half-life. With the exception of artesunate + sulfadoxine-pyrimethamine (AS+SP) combination, all ACTs are effective against the blood stage infections of P. vivax.

In order to prevent relapses, primaquine should be added to the treatment; dose and frequency of the administration should be guided by the patient’s glucose-6-phosphate dehydrogenase (G6PD) enzyme activity.

Treatment of severe malaria

Severe malaria should be treated with injectable artesunate (intramuscular or intravenous) for at least 24 hours and followed by a complete 3-day course of an ACT once the patient can tolerate oral medicines. When injectable treatment cannot be given, children under 6 years of age with severe malaria should receive a pre-referral treatment with rectal artesunate before being referred immediately to a health care facility where the full level of care can be provided.

It is essential that neither artemisinin-based injectables nor artesunate suppositories be used as monotherapies – the initial treatment of severe malaria with these medicines needs to be completed with a 3-day course of an ACT. This is to ensure complete cure and prevent the development of resistance to the artemisinin derivatives.

Expansion of access to ACTs

In recent years, access to ACTs has expanded substantially. By the end of 2016, ACTs had been adopted as first-line treatment policy in 80 countries. An estimated 409 million treatment courses of artemisinin-based combination therapy (ACT) were procured by countries in 2016, an increase from 311 million in 2015. Over 69% of these procurements were reported to have been made for the public sector. The number of ACT treatments distributed through the public sector increased from 192 million in 2013 to 198 million in 2016. Most (99%) occurred in the WHO African Region.

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