Appendix C: Malaria Diagnosis and Treatment Quick Reference

Malaria diagnosis and treatment quick reference²

Initial clinical evaluation and disposition

• Suspect malaria and perform diagnostic testing for febrile individuals who:
  • Report recent (weeks to 2 years) travel to a malaria-endemic country.
  • Do not have an alternative diagnosis for fever.
• If malaria is suspected in a patient, but malaria testing is not available at your facility, refer or transfer the patient immediately to a facility with malaria testing capacity.

Key diagnostic tests for malaria

• STAT thick and thin blood smear is the gold standard. Collect both for all suspected cases.
  • Blood smears detect parasites and determine parasite density and Plasmodium species. Obtain results rapidly (should not be a send-out test).
  • If the initial test is negative and suspicion for malaria is high, repeat the blood smear every 12–24 hours until positive, or until three tests are negative.
  • CDC can provide malaria diagnostic assistance. Contact parasiteslab@cdc.gov.
• STAT BinaxNOW™ Malaria Rapid Diagnostic Test (RDT)² can shorten the time to treatment but must be collected concurrently with a blood smear.

• Save a pre-treatment whole blood sample (purple top, EDTA tube) for testing by the public health laboratory if are concerned about antimalarial drug resistance/treatment failure or if malaria is in a patient with no recent international travel.

Treatment considerations

When a blood smear or RDT is positive, start treatment immediately, consider hospitalization, and consult with infectious disease specialists. Find dosing specifics and alternative treatment regimens in CDC's treatment tables, and contact the CDC Malaria Hotline³ if you have questions.

Treatment of the blood stage of malaria infections

• Malaria can be uncomplicated or severe. A patient has severe disease if they meet ONE OR MORE of the following criteria:
  • Parasitemia ≥5%
  • Impaired consciousness, coma, seizures
  • Circulatory collapse/shock
  • Acidosis
  • Pulmonary edema or acute respiratory distress syndrome
  • Acute kidney injury
  • Disseminated intravascular coagulation (DIC)
  • Severe anemia (hemoglobin <7 g/dL)
  • Jaundice (with other signs of severe malaria)
• Treat severe malaria with IV artesunate. Find information on how to acquire IV artesunate in the United States on CDC's malaria website.
• The parasite's species and country of origin (a proxy for chloroquine sensitivity) should guide drug selection (see first column in CDC's treatment tables for further guidance).
• Treat uncomplicated malaria due to Plasmodium falciparum (or if species unknown) with oral antimalarials for chloroquine-resistant malaria.
  • The preferred treatment is artemether-lumefantrine (Coartem®); atovaquone-proguanil (Malarone®) is the next best option.⁴
• Treat uncomplicated malaria due to Plasmodium vivax (from most countries⁵) or ovale, with chloroquine or hydroxychloroquine. If chloroquine/hydroxychloroquine is not available, use an antimalarial drug for chloroquine-resistant malaria (e.g., artemether-lumefantrin [Coartem®]).
• Additional treatment is needed to the eliminate the liver hypnozoites of P. vivax and P. ovale which cause relapse malaria.

To prevent relapse of confirmed P. vivax and P. ovale malaria, treat the liver hypnozoite.

Start primaquine or tafenoquine as soon as quantitative G6PD result is available, not before.

If G6PD is normal:

• Primaquine: Preferred option (adult dose = 30 mg base per day x 14 days)
  • Give primaquine with food to reduce gastrointestinal side effects.
  • The total dose of primaquine determines effectiveness. When doses are missed, the patient should continue to take the same daily dose for as many days as is needed to complete the course.
  • For patients > 70 kg, increase the dose to 6mg/kg base total, divided into 30 mg/day doses for as many days as needed (e.g., 100 kg patient, 30 mg base for 20 days). Max daily dose 30 mg base.
  • Contraindications: pregnant or breastfeeding people, or people with G6PD deficiency (intermediate G6PD deficiency requires dose adjustment, see below)

• Tafenoquine: Tafenoquine 300 mg single dose is an option for adults (only if chloroquine was given for blood stage therapy)
  • Avoid tafenoquine if the patient's weight is over 70 kg
  • Contraindications: <16 years of age, pregnant or breastfeeding people, or people with G6PD deficiency of any severity (G6PD activity <70%)
  • Not recommended: in patients with psychiatric illness

If G6PD is intermediate:

• Primaquine adjustment: 45 mg base (adult dose) per week for 8 weeks with close monitoring for hemolysis

If there is G6PD deficiency:

• Chloroquine 300 mg base (adult dose) weekly for 1 year

Pregnant people can take Chloroquine 300 mg base weekly until delivery.

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²Package insert for BinaxNOW Malaria test: https://www.globalpointofcare.abbott/us/en/product-details/binaxnow-malaria.html

³Email malaria@cdc.gov or call Mon – Fri, 9 am – 5 pm EST 770-488-7788 or 855-856-4713. (After hours call 770-488-7100.)

⁴Use of trade names is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry, the Public Health Service, or the U.S. Department of Health and Human Services

⁵Chloroquine-resistant P. vivax is currently found in Papua New Guinea and Indonesia.