Guidelines for the treatment of malaria in malawi

Objectives

Malawi’s fourth edition national malaria treatment guidelines, issued by the Ministry of Health in July 2013, provide policy and clinical guidance for diagnosing and managing uncomplicated and severe malaria, malaria in pregnancy, coma assessment, and selective chemoprophylaxis.[1][2][3]They seek to support prompt, adequate case management, reduce malaria morbidity and mortality, and lessen the socioeconomic burden of malaria, particularly among children under five years.[4][5]

• Strengthen parasitological confirmation of suspected uncomplicated malaria through microscopy or malaria rapid diagnostic tests before treatment.[6]
• Use artemisinin-based combination therapy to preserve antimalarial effectiveness, prohibit oral artemisinin monotherapy, and use lumefantrine-artemether as first-line treatment for uncomplicated malaria.[5][6][7]
• Reserve artesunate-amodiaquine for confirmed first-line treatment failure and use quinine-based regimens where indicated for subsequent failure or specific high-risk groups.[8][9]
• Manage severe malaria as a medical emergency through immediate pre-referral treatment, urgent referral, hospital-based parenteral treatment, supportive care, and subsequent completion of oral therapy.[9][10][11]
• Protect pregnant women and infants through prompt malaria treatment, prevention measures, and intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine after the first trimester.[12]
• Provide selective chemoprophylaxis for defined high-risk groups and visitors from non-endemic countries, alongside insecticide-treated nets and prompt assessment of fever.[13]

Implementation

The Ministry of Health, through the National Malaria Control Programme, leads and coordinates the malaria response with government and development partners.[4]Guideline development and revision draw on technical leadership, evidence review, consultation, and contributions from Ministry units, research institutions, the National Malaria Advisory Committee, the Clinton Health Access Initiative, the President’s Malaria Initiative, UNICEF, and the World Health Organization.[5]Implementation follows differentiated diagnostic, treatment, referral, inpatient, antenatal, and community pathways.[2][3]

• Test suspected uncomplicated cases at all levels using malaria rapid diagnostic tests, while using microscopy where capacity permits for severe malaria, treatment monitoring, treatment-failure confirmation, parasite identification, and density assessment.[6][7]The Ministry recommends SD Bioline malaria Ag Pf and Paracheck malaria Ag Pf histidine-rich protein-2 tests.[6][7]
• Provide lumefantrine-artemether as standard first-line treatment, using dispersible tablets for children weighing 5 kg to under 25 kg and conventional tablets for patients weighing 25 kg or more.[14]Administer six doses over three days, give doses with food, and repeat a dose if vomiting occurs within 30 minutes.[15]Dispersible treatment is available through government and Christian Health Association of Malawi facilities and community village clinics.[15]
• Tailor uncomplicated-malaria treatment for pregnancy and very small children: use oral quinine plus clindamycin in the first trimester and for children below 5 kg, and lumefantrine-artemether in the second and third trimesters.[6][15][16]
• Assess suspected treatment failure using blood-film confirmation and review of adherence, diagnosis, dose, vomiting, interactions, medicine quality, and potential resistance.[8]Treat confirmed failure within 14 days with artesunate-amodiaquine, with quinine plus doxycycline or clindamycin after artesunate-amodiaquine failure as appropriate.[8][9]
• Initiate rectal artesunate immediately for suspected severe malaria in the community and refer without delay.[10]At health-centre level, give intramuscular artesunate, use intramuscular quinine only when artesunate is unavailable or contraindicated, and use rectal artesunate if neither injectable option is available.[17]Refer all suspected severe cases to hospital for evaluation and definitive management.[10]
• Deliver definitive severe-malaria treatment at district and central hospitals with parenteral artesunate, using parenteral quinine only when artesunate is unavailable or contraindicated.[6][11]Provide resuscitation, diagnostic testing, glucose and fluid management, fever and seizure control, management of anaemia and respiratory or renal complications, and assessment for concurrent illness.[18][19][20][11]Change to a full oral regimen once oral treatment is tolerated after at least 24 hours of parenteral therapy.[11]
• Monitor severe cases through microscopy and bedside assessment, including consciousness, vital signs, fluid balance, blood glucose, anaemia, convulsions, and functional recovery.[7][11]Use the Blantyre Coma Scale for children under 12 years and the Glasgow Coma Scale for older patients with suspected cerebral malaria.[21]
• Integrate prevention and treatment in antenatal and maternal and child health services, encourage early antenatal attendance, deliver at least three directly observed sulfadoxine-pyrimethamine doses after quickening at intervals of at least four weeks, and exclude women receiving cotrimoxazole prophylaxis.[12][21]
• Support selective chemoprophylaxis through healthcare workers, primary healthcare services, and village structures, explaining regimens to patients or guardians to support adherence.[22]

Monitoring & Evaluation

Monitoring is principally clinical and treatment-focused. The guidelines use diagnostic confirmation, bedside reassessment and targeted follow-up to guide malaria case management, but do not set out a comprehensive programme monitoring and evaluation framework, routine reporting architecture, surveillance governance structure or formal accountability system.[6][7][11]

• Confirm suspected uncomplicated malaria using microscopy or a malaria rapid diagnostic test before treatment, and use microscopy as the diagnostic gold standard where capacity is available.[6][7]
• Use microscopy to monitor severe-malaria treatment progress, confirm suspected first-line treatment failure before second-line treatment, identify parasite species and assess parasite density.[7]
• Record infection status, parasite stage and parasite count on laboratory result forms, using the prescribed interpretation of parasite density.[7]
• Assess potential treatment failure where symptoms persist or deterioration occurs three to 14 days after treatment starts, confirming parasitaemia by blood film and reviewing adherence, diagnosis, dose, vomiting, drug interactions and medicine quality.[8]
• Classify illness occurring 14 days or more after prior symptoms cleared as a new infection, while repeating first-line treatment where previous diagnosis, adherence or dosage was incorrect.[8]
• Evaluate severe malaria through clinical and laboratory findings, including altered consciousness, respiratory distress, convulsions, shock, severe anaemia, hypoglycaemia, hyperlactataemia, electrolyte disturbance, acute kidney injury and haemoglobinuria.[9]
• Monitor admitted severe-malaria patients using Critical Care Pathways where possible, including consciousness level, vital signs every four hours, fluid balance, anaemia, convulsions, blood glucose while unconscious or during convulsions, haemoglobin or packed cell volume when indicated, and recovery of functional abilities such as drinking, eating, sitting and walking.[11]
• Reassess blood glucose 30 minutes after intravenous dextrose and thereafter as required, recognising recurrent hypoglycaemia risk, especially among pregnant women and children.[18]
• Monitor fluid balance closely in adults with acute kidney injury and consider peritoneal dialysis where oliguria persists beyond several days.[11]
• Monitor consciousness in cerebral malaria by recording coma scores daily or more frequently, using the Blantyre Coma Scale for children under 12 years and the Glasgow Coma Scale for older children and adults.[21]
• Monitor blood glucose around quinine administration in pregnant women with severe malaria, alongside close observation for pulmonary oedema.[21]
• Apply directly observed therapy for intermittent preventive treatment in pregnancy and administer sulfadoxine-pyrimethamine doses at intervals of at least four weeks.[12]
• Conduct a baseline retinal examination for people expected to use weekly chloroquine prophylaxis for more than five years, followed by annual examinations after five years of use.[22]
• Use evidence from regular sentinel-site studies and selected research institutions to inform treatment policy, as declining sulfadoxine-pyrimethamine efficacy contributed to the change in first-line therapy.[5]

No programme-level indicator set, numerical targets, routine reporting schedule, data-review process, surveillance system beyond cited sentinel-site studies, or institutional accountability mechanism is specified in the supplied material.[5][6][7]

Costing & Financing

The supplied material contains very limited financing information. It identifies malaria as imposing household and socioeconomic costs and notes relative medicine expense and availability, but does not provide a programme budget, financing plan, resource-mobilisation strategy, quantified funding gap, allocation or formal economic assumptions.[4][22]

• Recognise malaria as a socioeconomic burden associated with lost work, school absenteeism and high treatment expenditure, particularly for poorer households.[4]
• Note that lumefantrine-artemether was more expensive than sulfadoxine-pyrimethamine when adopted as first-line treatment, although no prices or comparative cost estimates are provided.[4]
• Identify medicine and service inputs required for implementation, including rapid diagnostic tests, microscopy, antimalarial medicines, injectable treatment, diluents, intravenous fluids, laboratory forms and clinical monitoring, without assigning costs or funding sources.[6][7][23]
• Recognise mefloquine as quite expensive and not widely available in Malawi.[22]
• Recognise atovaquone-proguanil as extremely expensive and suitable only for short-term prophylactic use.[22]

No monetary value, currency-denominated budget, donor commitment, domestic allocation, costed implementation plan, affordability threshold or economic evaluation is specified in the supplied text.[4][23][12][13][22]