Who / when
- Anyone with fever, or a history of fever, who lives in or has travelled from a malaria area.
- Children under 5: use the IMCI fever chart as well (danger signs, other causes of fever).
- Any sign of severe malaria: use the severe malaria pre-referral protocol instead.
Red flags: refer now
Treat as severe malaria and refer if there is any of these:
- Impaired consciousness, confusion or unusual sleepiness.
- Prostration: cannot sit, stand or walk without help (a child cannot sit or feed).
- More than two convulsions in 24 hours.
- Deep, laboured breathing or breathing difficulty.
- Vomiting everything, or unable to drink or swallow tablets.
- Very pale (severe anaemia), jaundice, unusual bleeding, very little urine, cold hands with a weak pulse (shock).
Severe malaria cannot waitGive pre-referral artesunate and refer at once. Do not start an oral ACT in a patient who cannot swallow or keep tablets down.
Assess
- Test every suspected case with an RDT or microscopy before treating. Treat only on a positive result.
- If no test is available and the patient is ill, follow your national rule for presumptive treatment and arrange a test.
- Ask about antimalarials taken in the last 1 to 2 months (a failure needs referral or second-line treatment).
- Ask about pregnancy in every woman of childbearing age.
- Weigh the patient: the dose goes by weight.
- Look for other causes of fever (pneumonia, ear, throat, urine, skin, measles) even if the test is positive.
Classify
| Finding | Classify as | Action |
|---|
| Any danger sign or sign of severity, with a positive test or no test possible | Severe malaria | Pre-referral artesunate; refer urgently |
| Positive RDT or slide, no sign of severity, can take oral medicine | Uncomplicated malaria | 3-day ACT by weight; treat fever; return advice |
| Negative test | Fever: not malaria | No antimalarial; look for and treat the other cause; return if fever persists |
Treat
Give a 3-day ACT (national first line)
WHO-recommended ACTs: artemether-lumefantrine (AL), artesunate-amodiaquine, artesunate-mefloquine, dihydroartemisinin-piperaquine, artesunate + sulfadoxine-pyrimethamine and artesunate-pyronaridine. Give 3 days; shorter courses are not effective.
Twice daily for 3 days: six doses. Give the first two doses about 8 hours apart. Take with food or a milky drink.| Body weight | AL tablets (20 mg/120 mg) per dose |
|---|
| 5 to under 15 kg | 1 |
| 15 to under 25 kg | 2 |
| 25 to under 35 kg | 3 |
| 35 kg and over | 4 |
- Give the first dose in the clinic. If it is vomited within an hour, repeat it; if vomiting continues, treat as severe.
- Infants under 5 kg: give an ACT at the same mg/kg dose as a 5 kg child; use the new infant AL formulation if your programme has it.
- First trimester of pregnancy: artemether-lumefantrine. Second and third trimesters: the national first-line ACT. Never use an ACT containing sulfadoxine-pyrimethamine in the first trimester.
- Low-transmission areas: add a single dose of primaquine 0.25 mg/kg to reduce spread (not in pregnancy or in infants under 1 month). No G6PD test is needed for this dose.
- P. vivax or P. ovale: ACT (or chloroquine where it still works), then primaquine to prevent relapse, per national guideline and G6PD policy.
- Fever above 38.5 °C: paracetamol (15 mg/kg every 4 to 6 hours in children).
Follow-up
- Ask the patient to come back if the fever is still there after 3 days, or at once if any danger sign appears.
- At review: reassess fully. Do not repeat an HRP2-based RDT, as it can stay positive for weeks; use microscopy if available.
- Fever or parasites coming back within 28 days of a full course: treat as treatment failure (second-line ACT or refer).
- Check that the course was finished and that no doses were vomited.
Counsel
- Take every dose, at the right times, with food, even when you feel better.
- Sleep under an insecticide-treated net every night, especially young children and pregnant women.
- Return at once if you get worse, cannot drink, vomit the medicine, become drowsy, have fits or breathe fast.
This test shows malaria. Take these tablets twice a day for three days with food, all of them. Come back straight away if you become very weak, drowsy, keep vomiting, or have fits.
When to refer
- Urgently: any danger sign or sign of severe malaria (give pre-referral artesunate first).
- Repeated vomiting of the ACT.
- Pregnant woman with malaria and any complication, or a first-trimester woman if AL is not available.
- Fever persisting after a full course, or recurrence within 28 days, if you have no second-line ACT or microscopy.
- Fever every day for more than 7 days with no cause found.
Sources
World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014.