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Guidelines for the treatment of malaria – 2 edition

6.4 in stable high-transmission settings
Parasitological confirmation of the diagnosis of malaria provided by high-quality
microscopy or, where this is not available, by RDTs is recommended for all suspected
cases of malaria. High-transmission settings include most areas in some parts of Oceania
and sub-Saharan Africa. In these settings, slide positivity rate in children under five years
of age with fever is more than 5%.

A parasitological confirmation of malaria in stable high-transmission settings is
recommended; it improves the differential diagnosis of fever, improves fever case
management, and reduces unnecessary use of antimalarial medicines. Antimalarial
treatment on the basis of clinical suspicion of malaria should only be considered in
situations where a parasitological diagnosis is not accessible. This consideration is of high
significance particularly in vulnerable populations (e.g. children under five years of age,
pregnant women, suspected severe malaria cases, and in settings with a high prevalence of
HIV/AIDS where the patients present with fever or a history of fever and no other obvious
cause of the fever is present) in whom the disease can rapidly become fatal.

6.5 malaria parasite species identification

In areas where two or more species of malaria parasites are common, only the
parasitological method will permit a species diagnosis. Where mono-infection with
P. vivax is common and microscopy is not available, it is recommended that a combination
RDT, which contains a pan-malarial antigen, is used. Where P. vivax, P. malariae or
P. ovale occur, almost always as a co-infection with P. falciparum, an RDT detecting
P. falciparum alone may be sufficient; the treatment for non-falciparum malaria is given
only to cases with a negative test result and where no other obvious cause of illness is
present. Anti-relapse treatment with primaquine should only be given to cases with
confirmed diagnosis of P. vivax or P. ovale malaria, and in the absence of contraindications
such as glucose-6-phosphate dehydrogenase (G6PD) deficiency.

6.6 in epidemics and complex emergencies

In epidemic and complex emergency situations, facilities for parasitological diagnosis may
be unavailable or inadequate to cope with the case-load. In such circumstances, it may
be impractical and unnecessary to demonstrate parasites before treatment in all cases of
fever (see details in Section 11.1).

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