MALARIA such as puddles, rice fields, and hoof prints.

Transmission is more intense

in places where the mosquito lifespan is longer (so that the parasite has
time to complete its development inside the mosquito) and where it
prefers to bite humans rather than other animals. For example, the long
Malaria is caused by Plasmodium parasites. The parasites are spread to lifespan and strong human-biting habit of the African vector species is the
people through the bites of infected Anopheles mosquitoes, called main reason why more than 90% of the world's malaria deaths are in
"malaria vectors", which bite mainly between dusk and dawn. Africa.

There are four parasite species that cause malaria in humans: Transmission also depends on climatic conditions that may affect the
number and survival of mosquitoes, such as rainfall patterns,
 Plasmodium falciparum temperature and humidity. In many places, transmission is seasonal, with
 Plasmodium vivax the peak during and just after the rainy season. Malaria epidemics can
 Plasmodium malariae occur when climate and other conditions suddenly favour transmission in
 Plasmodium ovale. areas where people have little or no immunity to malaria. They can also
occur when people with low immunity move into areas with intense
malaria transmission, for instance to find work, or as refugees.
Plasmodium falciparum and Plasmodium vivax are the most common.
Plasmodium falciparum is the most deadly.
Human immunity is another important factor, especially among adults in
areas of moderate or intense transmission conditions. Partial immunity is
In recent years, some human cases of malaria have also occurred with
developed over years of exposure, and while it never provides complete
Plasmodium knowlesi – a species that causes malaria among monkeys
protection, it does reduce the risk that malaria infection will cause severe
and occurs in certain forested areas of South-East Asia.
disease. For this reason, most malaria deaths in Africa occur in young
children, whereas in areas with less transmission and low immunity, all
Transmission
age groups are at risk.
Malaria is transmitted exclusively through the bites of Anopheles
Symptoms
mosquitoes. The intensity of transmission depends on factors related to
the parasite, the vector, the human host, and the environment.
Malaria is an acute febrile illness. In a non-immune individual, symptoms
appear seven days or more (usually 10–15 days) after the infective
About 20 different Anopheles species are locally important around the
mosquito bite. The first symptoms – fever, headache, chills and vomiting
world. All of the important vector species bite at night. Anopheles
– may be mild and difficult to recognize as malaria. If not treated within
mosquitoes breed in water and each species has its own breeding
24 hours, P. falciparum malaria can progress to severe illness often
preference; for example some prefer shallow collections of fresh water,
leading to death. Children with severe malaria frequently develop one or
more of the following symptoms: severe anaemia, respiratory distress in  people with HIV/AIDS;
relation to metabolic acidosis, or cerebral malaria. In adults, multi-organ  international travellers from non-endemic areas because they
involvement is also frequent. In malaria endemic areas, persons may lack immunity;
develop partial immunity, allowing asymptomatic infections to occur.  immigrants from endemic areas and their children living in non-
endemic areas and returning to their home countries to visit
For both P. vivax and P. ovale, clinical relapses may occur weeks to friends and relatives are similarly at risk because of waning or
months after the first infection, even if the patient has left the malarious absent immunity.
area. These new episodes arise from dormant liver forms known as
hypnozoites (absent in P. falciparum and P. malariae); special treatment – Diagnosis and treatment
targeted at these liver stages – is required for a complete cure.
Early diagnosis and treatment of malaria reduces disease and prevents
Who is at risk? deaths. It also contributes to reducing malaria transmission.

Approximately half of the world's population is at risk of malaria. Most The best available treatment, particularly for P. falciparum malaria, is
malaria cases and deaths occur in sub-Saharan Africa. However, Asia, artemisinin-based combination therapy (ACT).
Latin America, and to a lesser extent the Middle East and parts of Europe
are also affected. In 2011, 99 countries and territories had ongoing WHO recommends that all cases of suspected malaria be confirmed using
malaria transmission. parasite-based diagnostic testing (either microscopy or rapid diagnostic
test) before administering treatment. Results of parasitological
Specific population risk groups include: confirmation can be available in 15 minutes or less. Treatment solely on
the basis of symptoms should only be considered when a parasitological
 young children in stable transmission areas who have not yet diagnosis is not possible. More detailed recommendations are available in
developed protective immunity against the most severe forms of the Guidelines for the treatment of malaria (second edition).
the disease;
 non-immune pregnant women as malaria causes high rates of Antimalarial drug resistance
miscarriage and can lead to maternal death;
 semi-immune pregnant women in areas of high transmission. Resistance to antimalarial medicines is a recurring problem. Resistance of
Malaria can result in miscarriage and low birth weight, especially P. falciparum to previous generations of medicines, such as chloroquine
during first and second pregnancies; and sulfadoxine-pyrimethamine (SP), became widespread in the 1970s
 semi-immune HIV-infected pregnant women in stable and 1980s, undermining malaria control efforts and reversing gains in
transmission areas, during all pregnancies. Women with malaria child survival.
infection of the placenta also have a higher risk of passing HIV
infection to their newborns;
In recent years, parasite resistance to artemisinins has been detected in Two forms of vector control are effective in a wide range of
four countries of the Greater Mekong subregion: Cambodia, Myanmar, circumstances.
Thailand and Viet Nam. While there are likely many factors that
contribute to the emergence and spread of resistance, the use of oral Insecticide-treated mosquito nets (ITNs)
artemisinins alone, as monotherapy, is thought to be an important driver.
When treated with an oral artemisinin-based monotherapy, patients may Long-lasting insecticidal nets (LLINs) are the preferred form of ITNs for
discontinue treatment prematurely following the rapid disappearance of public health distribution programmes. WHO recommends coverage for
malaria symptoms. This results in incomplete treatment, and such all at-risk persons; and in most settings. The most cost effective way to
patients still have persistent parasites in their blood. Without a second achieve this is through provision of free LLINs, so that everyone sleeps
drug given as part of a combination (as is provided with an ACT), these under a LLIN every night.
resistant parasites survive and can be passed on to a mosquito and then
another person. Indoor spraying with residual insecticides

If resistance to artemisinins develops and spreads to other large Indoor residual spraying (IRS) with insecticides is a powerful way to
geographical areas, the public health consequences could be dire, as no rapidly reduce malaria transmission. Its full potential is realized when at
alternative antimalarial medicines will be available for at least five years. least 80% of houses in targeted areas are sprayed. Indoor spraying is
effective for 3–6 months, depending on the insecticide used and the type
WHO recommends the routine monitoring of antimalarial drug resistance, of surface on which it is sprayed. DDT can be effective for 9–12 months in
and supports countries to strengthen their efforts in this important area some cases. Longer-lasting forms of existing IRS insecticides, as well as
of work. new classes of insecticides for use in IRS programmes, are under
development.
More comprehensive recommendations are available in the WHO Global
Plan for Artemisinin Resistance Containment (GPARC), which was released Antimalarial medicines can also be used to prevent malaria. For travellers,
in 2011. malaria can be prevented through chemoprophylaxis, which suppresses
the blood stage of malaria infections, thereby preventing malaria disease.
Prevention In addition, WHO recommends intermittent preventive treatment with
sulfadoxine-pyrimethamine for pregnant women living in high
Vector control is the main way to reduce malaria transmission at the transmission areas, at each scheduled antenatal visit after the first
community level. It is the only intervention that can reduce malaria trimester. Similarly, for infants living in high-transmission areas of Africa,
transmission from very high levels to close to zero. 3 doses of intermittent preventive treatment with sulfadoxine-
pyrimethamine is recommended delivered alongside routine vaccinations.
For individuals, personal protection against mosquito bites represents the In 2012, WHO recommended Seasonal Malaria Chemoprevention as an
first line of defence for malaria prevention. additional malaria prevention strategy for areas of the Sahel sub-Region
of Africa. The strategy involves the administration of monthly courses of 2012. The GPIRM puts forward a five-pillar strategy calling on the global
amodiaquine plus sulfadoxine-pyrimethamine to all children under 5 malaria community to:
years of age during the high transmission season.
 plan and implement insecticide resistance management
Insecticide resistance strategies in malaria-endemic countries;
 ensure proper and timely entomological and resistance
Much of the success to date in controlling malaria is due to vector monitoring, and effective data management;
control. Vector control is highly dependent on the use of pyrethroids,  develop new and innovative vector control tools;
which are the only class of insecticides currently recommended for ITNs  fill gaps in knowledge on mechanisms of insecticide resistance
or LLINs. In recent years, mosquito resistance to pyrethroids has emerged and the impact of current insecticide resistance management
in many countries. In some areas, resistance to all four classes of approaches; and
insecticides used for public health has been detected. Fortunately, this  ensure that enabling mechanisms (advocacy as well as human
resistance has only rarely been associated with decreased efficacy, and and financial resources) are in place.
LLINs and IRS remain highly effective tools in almost all settings.
Surveillance
However, countries in sub-Saharan Africa and India are of significant
concern. These countries are characterized by high levels of malaria Tracking progress is a major challenge in malaria control. Malaria
transmission and widespread reports of insecticide resistance. The surveillance systems detect only around 10% of the estimated global
development of new, alternative insecticides is a high priority and several number of cases. Stronger malaria surveillance systems are urgently
promising products are in the pipeline.. Development of new insecticides needed to enable a timely and effective malaria response in endemic
for use on bed nets is a particular priority. regions, to prevent outbreaks and resurgences, to track progress, and to
hold governments and the global malaria community accountable. In
Detection of insecticide resistance should be an essential component of April 2012, the WHO Director-General launched new global surveillance
all national malaria control efforts to ensure that the most effective manuals for malaria control and elimination, and urged endemic
vector control methods are being used. The choice of insecticide for IRS countries to strengthen their surveillance systems for malaria. This was
should always be informed by recent, local data on the susceptibility embeddedpart of in a larger call to scale up diagnostic testing, treatment
target vectors. and surveillance for malaria, known as WHO’s T3: Test. Treat. Track
initiative.
In order to ensure a timely and coordinated global response to the threat
of insecticide resistance, WHO has worked with a wide range of Elimination
stakeholders to develop the Global Plan for Insecticide Resistance
Management in malaria vectors (GPIRM), which was released in May Malaria elimination is defined as interrupting local mosquito-borne
malaria transmission in a defined geographical area, i.e. zero incidence of
locally contracted cases. Malaria eradication is defined as the permanent
reduction to zero of the worldwide incidence of malaria infection caused
by a specific agent; i.e. applies to a particular malaria parasite species.

Many countries – especially in temperate and sub-tropical zones – have

been successful in eliminating malaria. The global malaria eradication
campaign, launched by WHO in 1955, was successful in eliminating the
disease in some countries, but ultimately failed to achieve its overall goal,
thus being abandoned less than two decades later in favour of the less
ambitious goal of malaria control. In recent years, however, interest in
malaria eradication as a long-term goal has re-emerged.

Large-scale use of WHO-recommended strategies, currently available

tools, strong national commitments, and coordinated efforts with
partners, will enable more countries – particularly those where malaria
transmission is low and unstable – to progress towards malaria
elimination. In recent years, 4 countries have been certified by the WHO
Director-General as having eliminated malaria: United Arab Emirates
(2007), Morocco (2010), Turkmenistan (2010), and Armenia (2011).

Vaccines against malaria

There are currently no licensed vaccines against malaria or any other

human parasite. One research vaccine against P. falciparum, known as
RTS,S/AS01, is most advanced. This vaccine is currently being evaluated in
a large clinical trial in 7 countries in Africa. A WHO recommendation for
use will depend on the final results from the large clinical trial. These final
results are expected in late 2014, and a recommendation as to whether
or not this vaccine should be added to existing malaria control tools is
expected in 2015.

http://www.who.int/mediacentre/factsheets/fs094/en/