National Malaria Treatment Protocol 2019, Nepal – EDCD

Malaria case management, consisting of early diagnosis and prompt effective treatment, remains a vital component of malaria control and elimination strategies. This National Malaria Treatment Protocol 2019 contains updated recommendations based on national adaptation of global WHO recommendations to provide guidance to health workers to ensure that optimal care is provided for malaria patients and contribute to achieving the goal of malaria elimination in Nepal by 2025.

Diagnosis of malaria

• Always obtain a travel history.
• All cases of suspected malaria should have a parasitological test (microscopy or RDT) to confirm the diagnosis. RDTs should be used when microscopy is not feasible.
• Use of both microscopy and RDTs should be supported by a quality assurance programme.

Treating uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria

• Treat with chloroquine (3 days) and primaquine (14 days) for P. vivax and P. ovale.
• Treat with chloroquine (3 days) for P. malariae or P. knowlesi.

Blood stage infection

• 1st line – chloroquine
• 2nd line (chloroquine-resistance infection) – dihydroartemisinin + piperaquine

Preventing relapse in P. vivax or P. ovale malaria

• 14-day course of primaquine – (except pregnant women, infants aged < 6 months, and women breastfeeding infants aged < 6 months).
• G6PD testing is encouraged prior to 14 days PQ therapy but in case testing is not available closely supervised 14 days PQ therapy will be given.
• Counselling should be done to patient and followed up on days 3-7-14 days to monitor for adverse effects and compliance with primaquine.

Pregnant or breastfeeding women

• Treat with chloroquine for 3 days. Provide weekly chemoprophylaxis with chloroquine until delivery and breastfeeding are completed, then, treat with primaquine for 14 days to prevent future relapse.

Treating uncomplicated P. falciparum malaria

• Treat with AL (3 Days) and Primaquine on Day 1
• Treatment of uncomplicated P. falciparum malaria
  1st line – artemether + lumefantrine (AL)
  2nd line – dihydroartemisinin + piperaquine (DHA/PPQ)

Reducing the transmissibility of treated P. falciparum infections.

• Primaquine single dose of 0.25 mg/kg bw – (except in pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months). Testing for glucose-6-phosphate dehydrogenase (G6PD) is not required.

Pregnant or breastfeeding women

• Treat pregnant women all trimesters and lactating mothers with the first line ACT (AL) as in non-pregnant women. Provide primaquine single dose of 0.25 mg/kg bw after delivery and breastfeeding completed.

Treating severe malaria

• Intravenous or intramuscular artesunate for at least 24 hr. Once a patient has received at least 24 hr of parenteral therapy and can tolerate oral therapy, complete treatment with full course artemether + lumefantrine with single dose primaquine for falciparum and primaquine for radical cure of vivax (14 days).
• 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).

Pre-referral treatment

• A single intramuscular dose of artesunate and refer to an appropriate facility for further care.

Chemoprophylaxis

• Malaria prophylaxis is not necessary for in-country travel within Nepal.
• Prophylactic medication for malaria is recommended for Nepalese traveling to countries with areas of malaria transmission.
• The medicine of choice depends on the parasite species and resistance profile in the destination country.

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