South African Guidelines for the Prevention of Malaria

Objectives

Support South Africa’s malaria-elimination objective of zero local malaria transmission by 2018 by reducing malaria morbidity, mortality and exposure among residents and travellers in malaria-risk areas. The guidance frames prevention around risk awareness, mosquito-bite avoidance, appropriate chemoprophylaxis, early disease detection and effective treatment.[1][2]It prioritises prevention and prompt clinical action because delayed diagnosis and inappropriate treatment substantially contribute to complicated malaria and deaths.[3][4]

• Promote year-round personal protection against mosquito bites for residents and visitors in malaria-risk areas, particularly from dusk to dawn.[5][6]
• Target prevention and clinical awareness towards seasonal low-altitude risk areas in Limpopo, Mpumalanga and northern KwaZulu-Natal, while recognising that risk varies by locality, altitude, season, climate and population movement.[7][2]
• Provide healthcare workers with guidance on malaria transmission, bite prevention, chemoprophylaxis, drug interactions, contraindications and traveller-specific counselling.[1][8]
• Tailor preventive advice to destination risk, exposure duration, accommodation, night-time activities, medical conditions, concurrent medicines, pregnancy or breastfeeding, age, and likely adherence.[5][9]
• Prioritise protection for people at increased risk of severe malaria, including non-immune travellers, pregnant and breastfeeding women, young children, splenectomised people and immunocompromised patients.[6]
• Ensure early recognition of malaria in people with fever or compatible symptoms who live in, or have travelled to, transmission areas, regardless of season or previous prophylaxis.[3]
• Promote effective treatment as a medical emergency, using artemisinin-based combination therapy for uncomplicated Plasmodium falciparum malaria and injectable artesunate followed by combination therapy for severe malaria once oral treatment is tolerated.[4]

Implementation

Implementation combines government-managed vector control, individual mosquito avoidance, risk-based prescribing, timely diagnosis and appropriate treatment. The national Department of Health developed the guidelines with malaria experts, the South African Malaria Elimination Committee, the National Institute for Communicable Diseases, provincial health departments, universities and other technical stakeholders.[5][8]The source does not specify a programme-level monitoring framework, indicators, reporting arrangements, accountability mechanisms, budgets or financing sources.[1][5]

• Maintain annual indoor residual spraying through provincial malaria-control programmes, complemented where appropriate by larviciding, drainage of breeding sites, settlement planning away from marshy areas and water bodies, and mosquito-proof housing.[6]
• Protect people through reduced outdoor exposure between dusk and dawn, covering clothing, safe use of repellents, screened accommodation, insecticide-treated nets, indoor insecticide measures, and fans or air conditioning.[10][11]
• Assess travel risk using current information from credible health-information services and consider travel during the lower-risk dry period from June to August where feasible, rather than the higher-transmission wet summer period from September to May.[2]
• Use chemoprophylaxis only alongside, rather than instead of, non-drug protection, weighing malaria risk against serious medicine-related adverse effects.[11][12]
• Select mefloquine, doxycycline or atovaquone-proguanil according to local resistance patterns, co-morbidities, interactions, pregnancy or breastfeeding status, age and weight, anticipated activities, duration of stay and adherence.[5][4]
• Start prophylaxis before exposure and continue it after departure according to the selected regimen: mefloquine is generally weekly and continued for four weeks after leaving, doxycycline is daily and continued for four weeks, and atovaquone-proguanil is daily and continued for seven days.[12][13]
• Support adherence through counselling, including taking weekly medicines on the same day and daily medicines at the same time; use weight-based paediatric doses where indicated.[12][13]
• Avoid high-risk travel by pregnant people and children under five years where possible; where travel is unavoidable, apply meticulous bite prevention and appropriate clinical advice. Breastfed infants require their own recommended prophylactic dose because breast-milk drug levels are insufficient for protection.[14][15]
• Manage contraindications and interactions carefully, including avoiding mefloquine in epilepsy and psychiatric conditions, avoiding doxycycline in pregnancy and in children under eight years, and using caution with renal or hepatic impairment and anticoagulants.[16][17]
• Use doxycycline as the identified recommended option for travellers receiving antiretroviral therapy, while assessing possible interactions with immunosuppressants and other concurrent medicines; where interactions are possible, begin prophylaxis sufficiently early to permit plasma-level measurement.[18][19]
• Confirm suspected malaria through microscopy or rapid diagnostic testing, repeat testing when clinical suspicion remains high after a negative result, and use quality-assured microscopy where possible to verify rapid-test findings.[3][20]
• Train rapid-diagnostic-test users in storage, specimen collection, buffer use, timing, control-line checks, result recording and interpretation, recognising that rapid tests cannot determine severity or confirm parasite clearance.[3][20]
• Provide stand-by emergency treatment only for travellers unable to obtain medical attention within 24 hours of symptoms, using artemether-lumefantrine as the identified option for uncomplicated falciparum malaria and advising urgent subsequent clinical assessment.[21]

Monitoring & Evaluation

Monitoring is principally clinical and diagnostic rather than a defined programme-level evaluation system. The guidance emphasises early recognition of malaria in anyone with fever or compatible symptoms who lives in, or has travelled to, a transmission area, regardless of season or prior chemoprophylaxis, because delayed diagnosis and inappropriate treatment contribute to severe disease and death.[3]It does not set out a consolidated monitoring and evaluation framework, routine performance indicators, reporting schedule, surveillance targets, evaluation timetable or formal accountability arrangements.[1][5][22][4][23]

• Monitor changing malaria risk, local transmission conditions and parasite drug-resistance patterns when updating prevention advice and selecting chemoprophylaxis. Risk may change with location, altitude, season, rainfall, temperature and population movement, while changing resistance may require revision of prevention and treatment recommendations.[8][2]
• Assess adherence, adverse effects and relevant clinical parameters during chemoprophylaxis. Specific patient-level measures include international normalised ratio monitoring for people using warfarin, blood-glucose monitoring for diabetic travellers, plasma-level measurement before departure where prophylaxis may interact with antiretroviral therapy, and digoxin-level monitoring when digoxin is used with mefloquine.[16][24][18][19]
• Identify medicine-safety concerns that may necessitate discontinuation or a change of prophylaxis, including mefloquine-associated neuropsychiatric or visual effects, doxycycline-associated gastrointestinal effects and photosensitivity, and gastrointestinal effects with atovaquone-proguanil.[17][25]
• Watch for possible reduced effectiveness or interaction effects, including early signs of Plasmodium falciparum resistance to doxycycline, reduced doxycycline efficacy with rifampicin, and uncertain effects of anticonvulsants on doxycycline levels.[25][26][27]
• Confirm suspected malaria through microscopy or rapid diagnostic testing, and repeat testing or refer samples for further examination when an initial result is negative but clinical suspicion remains high.[3][28]
• Apply quality assurance to rapid diagnostic testing by following storage and procedural instructions, verifying the control line, reading tests within the stipulated time and recording results.[20]Use quality-assured microscopy to confirm rapid diagnostic test results where possible, particularly where malaria is clinically suspected despite a negative rapid test.[3]
• Recognise diagnostic limitations: rapid diagnostic tests cannot determine disease severity or confirm parasite clearance, may miss very low-density infections, and may yield false results because of technical or user error.[3]
• Maintain clinical detection after travel by taking a travel history covering the previous couple of months and considering malaria in patients with compatible febrile symptoms, including those who used prophylaxis.[13][28][29]
• Use reported prophylactic efficacy, estimated at about 90 per cent for the three recommended options, as contextual evidence for counselling rather than as a formal programme performance indicator. The strongest evidence is reported for mefloquine.[12]

Costing & Financing

No explicit costing, budget, funding source, financing arrangement, resource-mobilisation target, funding gap or economic assumption is specified across the supplied material.[1][5][18][19][3][20]

• Require clinical and diagnostic resources implied by the guidance, including medicines for chemoprophylaxis, rapid diagnostic tests, quality-assured microscopy, laboratory monitoring where indicated, vector-control activities and patient counselling, but no associated prices, allocations or financing mechanisms are provided.[6][16][24][3][20]
• Note that doxycycline is available from a pharmacy without prescription, whereas mefloquine and atovaquone-proguanil require a medical prescription; the material provides no comparison of medicine costs or affordability.[12]
• Recognise that annual indoor residual spraying is described as the mainstay of malaria vector control in South Africa and is normally delivered through provincial malaria-control programmes, but no programme budget or source of provincial funding is specified.[6]