World Malaria Day (25 April 2010)

The world witnesses 247 million people developing malaria every year, and one million deaths – mostly children under five. Families, governments, and donors spend considerable amounts in treating and preventing the disease, and this must be spent wisely and according to reliable evidence. Since malaria is transmitted by mosquitoes, effective mosquito control is important for reducing transmission. Reliable research carried out over the last 20 years has shown the high impact that can be achieved by mosquito nets impregnated with insecticide. Interventions developed longer ago, including spraying the inside of houses with insecticide, are accepted as being highly effective, but as a Cochrane Review published in Issue 4, 2010 shows, research studies are insufficient to quantify the effect. A number of questions remain including whether multiple mosquito control methods are needed and if so which are the best choices in areas with different intensities of malaria transmission.
Prompt treatment with effective drugs is vital for preventing death and also a central part of control in this condition. A recent Cochrane Review of artemisinin-based combination therapy clearly describes the current recommended treatment options for sick patients; while another challenged the accepted wisdom that iron supplementation should not be given in malaria endemic areas.

Mosquito Control to Prevent Malaria

Insecticide-treated nets for preventing malaria in pregnancy
Malaria in pregnancy has adverse effect on the mother and fetus. Protection with insecticide-treated nets during pregnancy is widely advocated, but evidence of their benefit has been inconsistent. This review compares the impact of insecticide-treated nets with no nets or untreated nets on preventing malaria in pregnancy. [Download PDF]

Insecticide-treated bed nets and curtains for preventing malaria
Insecticide-treated nets are widely used and promoted to prevent malaria. This review assesses the impact of insecticide-treated bed nets or curtains on mortality, malarial illness (life-threatening and mild), malaria parasitaemia, anaemia, and spleen rates. [Download PDF]

Indoor residual spraying for preventing malaria
Historically, indoor residual spraying (IRS) has reduced malaria transmission in many settings in the world, but the health effects of IRS are important to understand and will help compare IRS with other vector control interventions. This review summarizes available evidence in an effort to quantify the impact of IRS alone, and to compare the relative impacts of IRS and insecticide-treated nets, on key malariological parameters. [Download PDF]

Drugs for Preventing Malaria

Drugs for preventing malaria in pregnant women
Malaria contributes to maternal illness and anaemia in pregnancy, especially in first-time mothers, and can harm the mother and the baby. Drugs given routinely to prevent or mitigate the effects of malaria during pregnancy are often recommended. This review assesses drugs given to prevent malaria infection and its consequences in pregnant women living in malarial areas. This includes prophylaxis and intermittent preventive treatment. [Download PDF]

Chemoprophylaxis and intermittent treatment for preventing malaria in children
Malaria causes repeated illness in children living in endemic areas. Policies of giving antimalarial drugs at regular intervals (prophylaxis or intermittent treatment) are being considered for preschool children. This review evaluates prophylaxis and intermittent treatment with antimalarial drugs to prevent malaria in young children living in malaria-endemic areas. [Download PDF]

Malaria chemoprophylaxis in sickle cell disease
Malaria is the most common precipitating cause of crises in sickle cell disease in malaria-endemic countries. Health professionals often recommend life-long malaria chemoprophylaxis for people with sickle cell disease living in these areas. This review assesses the effects of routine malaria chemoprophylaxis in people with sickle cell disease. [Download PDF]

Preventing Malaria in Travellers

Electronic mosquito repellents for preventing mosquito bites and malaria infection
Electronic mosquito repellents (EMRs) are marketed to prevent mosquitoes biting and to prevent malaria. EMRs are small handheld, battery-powered EMRs intended to repel the female Anopheles mosquitoes that transmit malaria by emitting a high frequency buzz almost inaudible to the human ear. This review assesses whether EMRs prevent mosquito bites, and to assess any evidence of an effect on malaria infection. [Download PDF]

Drugs for preventing malaria in travellers
Malaria infects 10,000 to 30,000 international travellers each year. It can be prevented through anti-mosquito measures and drug prophylaxis. However, antimalarial drugs have adverse effects which are sometimes serious. This review compares the effects of currently used antimalarial drugs when given as prophylaxis to non-immune adult and child travellers who are travelling to regions with Plasmodium falciparum resistance to chloroquine. [Download PDF]

Vaccines for Preventing Malaria

Vaccines for preventing malaria (blood-stage)
A malaria vaccine is needed because of the heavy burden of mortality and morbidity due to this disease. Several blood (asexual)-stage vaccines are under development, but only one (MSP/RESA, also known as Combination B) has been tested in randomized controlled trials. This review assesses the effect of blood-stage malaria vaccines in preventing infection, disease, and death. [Download PDF]

Vaccines for preventing malaria (pre-erythrocytic)
Pre-erythrocytic vaccines act to prevent or delay a malaria attack by attacking the sporozoite and liver stages before the parasite reaches the bloodstream. This review assesses the efficacy and safety of pre-erythrocytic malaria vaccines against any type of human malaria. [Download PDF]

Vaccines for preventing malaria (SPf66)
SPf66 was one of the earliest vaccines developed. It is a synthetic peptide vaccine containing antigens from the blood stages of malaria linked together with an antigen from the sporozoite stage, and is targeted mainly against the blood (asexual) stages. This review assesses the effect of SPf66 malaria vaccines against Plasmodium falciparum, P. vivax, P. malariae, and P. ovale in preventing infection, disease, and death. [Download PDF]

Treatments for Uncomplicated Falciparum Malaria

Atovaquone-proguanil for treating uncomplicated malaria
Many conventional treatments for uncomplicated malaria are failing because malaria parasites develop resistance to them. One way to combat this resistance is to treat people with a combination of drugs, such as atovaquone-proguanil. This review compares atovaquone-proguanil with other antimalarial drugs (alone or in combination) for treating children and adults with uncomplicated Plasmodium falciparummalaria. [Download PDF]

Drugs for treating uncomplicated malaria in pregnant women
Women are more vulnerable to malaria during pregnancy, and malaria infection may have adverse consequences for the fetus. Identifying safe and effective treatments is important, and this review compares the effects of drug regimens for treating uncomplicated falciparum malaria in pregnant women.  [Download PDF]

Artemisinin-based combination therapy for treating uncomplicated malaria
The World Health Organization recommends uncomplicated Plasmodium falciparum malaria is treated using artemisinin-based combination therapy (ACT). This review aims to assist the decision making of malaria control programmes by providing an overview of the relative benefits and harms of ACTs versus other available ACT and non-ACT combinations for treating uncomplicated P. falciparum malaria. It is up to date as of 2009, and contains important information about dihydroartemisinin piperaquine. This review is the most relevant assessment of current treatment options. [Download PDF]

Reviews that have Guided Policy in the Past

Chlorproguanil-dapsone for treating uncomplicated malaria
In Africa, malaria is often resistant to chloroquine and sulfadoxine-pyrimethamine. Chlorproguanil-dapsone was considered a potential alternative, but it has since been withdrawn from use (2008) because of severe adverse effects. This review compares chlorproguanil-dapsone with other antimalarial drugs for treating uncomplicated falciparum malaria and highlights these problems. [Download PDF]

Artemether-lumefantrine (six-dose regimen) for treating uncomplicated falciparum malaria
The World Health Organization recommends artemether-lumefantrine for treating uncomplicated malaria. We sought evidence of superiority of the six-dose regimen over existing treatment regimens for treating uncomplicated falciparum malaria as well as its effectiveness in clinical situations. Subsequent to this review, we carried out a much wider assessment of all artemisinin-based combination treatments, so this review has been superseded. [Download PDF]

Artemether-lumefantrine (four-dose regimen) for treating uncomplicated falciparum malaria
The World Health Organization recommends artemisinin-based combination treatments, and one co-formulated product is artemether-lumefantrine. We sought evidence of the superiority of the four-dose regimen over existing treatments for uncomplicated falciparum malaria. Partly as a result of this review, the six-dose regimen is currently recommended, so this review is of historical interest. [Download PDF]

Amodiaquine for treating malaria
Amodiaquine has been widely used to treat malaria. Fatal adverse reactions have been reported in adults taking it for prophylaxis. This has led some authorities to suggest it is withdrawn as a first line treatment for malaria. This review compares amodiaquine with chloroquine or sulfadoxine-pyrimethamine for treating uncomplicated Plasmodium falciparum malaria. This review was important when it was first published in 1996, and led to the reintroduction of malaria in some countries. Since the World Health Organization recommended monotherapy no longer be used, and the global policy is to give drugs such as amodiaquine in combination with artemisinin derivatives, this review is of historical interest. [Download PDF]

Treatments for Severe Malaria (Including Adjunctive Treatment)

Routine anticonvulsants for treating cerebral malaria
Cerebral malaria is a common and potentially lethal complication of Plasmodium falciparum infection. People with cerebral malaria become unconscious, and often have protracted convulsions. This review evaluates whether giving anticonvulsant drugs routinely to people with cerebral malaria will improve the outcome of treatment and prevent death. [Download PDF]

Steroids for treating cerebral malaria
Cerebral malaria is associated with swelling of the brain. Corticosteroid drugs could reduce the harmful effects of this swelling, but they could also suppress host immunity to infection. This review assesses the effects of corticosteroid drugs in patients with cerebral malaria on death, life-threatening complications, and residual disability in survivors. [Download PDF]

Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria
The main treatment for cerebral malaria is parenteral antimalarial drugs. Mannitol and urea are used as adjunct therapy for cerebral malaria, but the World Health Organization does not recommend them. This review compares mannitol or urea to placebo or no treatment for treating children and adults with cerebral malaria. [Download PDF]

Blood transfusion for treating malarial anaemia
Blood transfusion is used in patients with severe malarial anaemia, but risks adverse reactions, transmission of disease, and is complicated to organize in developing countries. This review evaluates the effects of routine blood transfusion for severe anaemia on death and adverse outcomes in malarious areas. [Download PDF]

High first dose quinine regimen for treating severe malaria
Quinine is used for treating severe malaria, but there are arguments for giving an initial high dose. We assessed the clinical outcomes and adverse events of a high first (loading) dose regimen of quinine compared with a uniform (no loading) dose regimen in people with severe malaria. [Download PDF]

Intrarectal quinine versus intravenous or intramuscular quinine for treating Plasmodium falciparum malaria
In children with falciparum malaria, a proprietary quinine preparation (adjusted to make it less acidic) administered rectally may be easier to use and less painful than intramuscular or intravenous administration. However, rectal quinine may be less effective. This review compares intrarectal quinine with intravenous or intramuscular quinine for treating malaria caused by Plasmodium falciparum. Current research now focuses on the newer artemisinin derivatives. [Download PDF]

Iron-chelating agents for treating malaria
At one time, it was thought that iron-chelating agents may be useful adjuncts to malaria treatments. This review was carried out at that time. This review evaluates whether iron-chelating agents, such as intravenous desferrioxamine (DFO) and oral deferiprone, given alone or added to standard antimalarial treatment would reduce malaria deaths. Partly from the trial evidence, and partly from other information, iron-chelating agents are now no longer considered an option worthy of further research. [Download PDF]

Artemisinin derivatives for treating severe malaria
Artemisinin derivatives may have advantages over quinoline drugs for treating severe malaria since they are fast acting and effective against quinine resistant malaria parasites. This review assessed the effects of artemisinin drugs for severe and complicated falciparum malaria in adults and children. This review helped demonstrate their effectiveness, but has been superseded by reviews of individual drugs, and is no longer being updated. [Download PDF]

Treatment of Vivax Malaria

Primaquine for preventing relapses in people with Plasmodium vivax malaria
Plasmodium vivax infections contribute to a significant proportion of the malaria infections in many countries. Primaquine is the most widely used drug for treating the dormant liver stage. Different primaquine dosing regimens are in use. This review compares primaquine regimens for preventing relapses in people with P. vivax malaria. [Download PDF]

Treatment of Fever & Anaemia

Antipyretic measures for treating fever in malaria
Fever control measures are commonly used in treating malaria. In the past, some researchers suggested that fever reduction may prolong malaria illness. This review assesses whether antipyretic measures in malaria influences outcome, measured by length of illness, parasitaemia, and occurrence of convulsions. [Download PDF]

Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas
Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria. This review assesses the effect of iron on malaria and deaths. This is an important review informing current debates. [Download PDF]

Drug Delivery

Unit-dose packaged drugs for treating malaria
Unit-dose packaging of antimalarial drugs may improve the success of malaria treatments by making it easier for patients to take them correctly. This review summarizes the effects of unit-dose packaged treatment on treatment failure and treatment adherence in people with uncomplicated malaria. [Download PDF]

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