Updated WHO recommendations for malaria chemoprevention and elimination

3 June 2022

WHO published today in the consolidated guidelines for malaria a package of new and updated recommendations across a number of technical areas – from malaria chemoprevention and mass drug administration to elimination. The guidelines encourage countries to tailor the recommendations to local disease settings for maximum impact.

Clear, evidence-informed WHO recommendations guide managers of national malaria programmes as they develop polices and strategic plans to combat the disease; they support decisions around “what to do”. WHO also develops implementation guidance, such as operational and field manuals, to advise countries on “how to” deliver the recommended tools and strategies.

New and updated guidance

Intermittent preventive treatment of malaria in pregnancy (ITPp)

Malaria infection during pregnancy poses substantial risks not only to the mother, but also to her fetus and the newborn. Available evidence continues to show that intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a safe and highly cost-effective strategy for reducing the disease burden in pregnancy as well as adverse pregnancy and birth outcomes.

In updated guidance published today, WHO has reaffirmed its strong recommendation for the use of IPTp-SP in areas of moderate to high P. falciparum malaria transmission. The recommendation does not limit the delivery of IPT-SP to antenatal care (ANC) settings; where inequities in access to ANC services exist, other delivery methods, such as the use of community health workers, may be explored. IPT-SP is now recommended for all pregnant women, regardless of the number of pregnancies; previously, it was recommended only during a woman’s first and second pregnancies.

Perennial malaria chemoprevention (PMC) and seasonal malaria chemoprevention (SMC)

WHO has also updated its recommendations for 2 key malaria chemoprevention strategies: seasonal malaria chemoprevention (SMC) and perennial malaria chemoprevention (PMC – previously known as intermittent preventive treatment in infants, or IPTi). When given to young children, malaria chemoprevention has been shown to be a safe, effective and cost-effective strategy for reducing the disease burden and saving lives.

The updated WHO recommendations on SMC and PMC, published today, are less restrictive than the original recommendations; they do not specify strict age groups, transmission intensity thresholds, numbers of doses or cycles, or specific drugs. As such, they will support the broader use of chemoprevention among young children at high risk of severe malaria in areas with both seasonal and year-round transmission.

Intermittent preventive treatment of malaria in school-aged children (IPTsc)

WHO is also issuing a new recommendation for the use of intermittent preventive treatment of malaria in school-aged children (IPTsc) living in settings with moderate-to-high perennial or seasonal malaria transmission. The strategy and dosing schedule for IPTsc should cover children aged 5–15 years, and its introduction should not compromise chemoprevention interventions for children under 5 years of age, who are at highest risk of severe malaria.

Post-discharge malaria chemoprevention (PDMC)

WHO is issuing today a recommendation in favor of post-discharge malaria chemoprevention (PDMC). This is a strategy aimed at preventing malaria among children with severe anemia living in areas of moderate-to-high transmission after they are discharged from a hospital, when they are at high risk of re-admission or death. Through PDMC, children are given a full antimalarial treatment course at regular intervals.

Mass drug administration

WHO has also issued new guidance on mass drug administration (MDA), another chemoprevention strategy. Through MDA, all individuals in a target population are given a treatment course of antimalarial drugs, regardless of whether they are infected with malaria. The medication treats any existing malaria infections as well as new infections for a specific period of time.

The new recommendations on malaria MDA provide specific guidance to rapidly reduce the malaria disease burden in emergency settings and in areas of moderate to high transmission. They also provide guidance on the use of MDA to reduce P. falciparum malaria in very low to low transmission settings, and to reduce P. vivax transmission. The full set of MDA recommendations and supporting evidence can be found in the consolidated guidelines.

Elimination

The WHO global malaria strategy urges all malaria-endemic countries to accelerate progress towards the goal of elimination. In settings approaching elimination, interventions will be most effective at reducing transmission if they are tailored to detect and treat the residual foci of malaria transmission.

WHO has issued a new set of recommendations for the final phase of malaria elimination. Some of the recommendations are also relevant to areas that have achieved elimination and are working to prevent re-establishment of transmission. Based on available evidence, some recommendations are in favor of specific interventions (positive recommendations) and others against specific interventions (negative recommendations). The recommendations are divided into 3 categories:

• “mass” strategies applied to the entire population of a delimited geographical area, whether a hamlet, township or district, including: mass drug administration (described above); mass testing and treatment (MTaT); and mass relapse prevention (MRP).
• “targeted” strategies applied to people at increased risk of infection compared to the general population, including: targeted drug administration (TDA); targeted testing and treatment (TTaT); routine testing and treatment at points of entry (border screening); and malaria testing of organized or identifiable groups arriving or returning from malaria-endemic areas.
• “reactive” strategies triggered in response to individual cases, including: reactive drug administration (RDA); reactive case detection and treatment to reduce transmission of malaria (RACDT); and reactive indoor residual spraying (IRS).

Additional details can be found in the consolidated WHO Guidelines for malaria.

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