Malaria Prevention and Treatment

Simulation
Use the Koshland Science Museum simulation to determine the effect of various malaria
control measures in the following town:
Location
Population
Number of homes
Average household
size
Infection rate
Years of study

Control Measures
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets
Anti-malarial drugs
Indoor spraying
Bed nets

Namawala, Tanzania
4,758
868
5+
40%
5

Total Number of New

Infections

Challenge
Determine the best course of action for Namawala, Tanzania. Consider both the
effectiveness of the control measures and the cost to the village. Attempt to minimize
cost while providing as much malaria protection as possible. Include all relevant
calculations in your recommendation.

ChoosingaDrugtoPreventMalaria
Considerationswhenchoosingadrugformalariaprophylaxis:

Recommendationsfordrugstopreventmalariadifferbycountryoftravelandcanbefoundinthecountryspecifictablesof
theYellowBook.Recommendeddrugsforeachcountryarelistedinalphabeticalorderandhavecomparableefficacyinthat
country.

Noantimalarialdrugis100%protectiveandmustbecombinedwiththeuseofpersonalprotectivemeasures,(i.e.,insect
repellent,longsleeves,longpants,sleepinginamosquitofreesettingorusinganinsecticidetreatedbednet).

Forallmedicines,alsoconsiderthepossibilityofdrugdruginteractionswithothermedicinesthatthepersonmightbetaking
aswellasothermedicalcontraindications,suchasdrugallergies.

Whenseveraldifferentdrugsarerecommendedforanarea,thefollowingtablemighthelpinthedecisionprocess.

Drug

Reasonsthatmightmakeyouconsiderusingthis
drug

Atovaquone/Proguanil
(Malarone)

Goodforlastminutetravelersbecausethe
drugisstarted12daysbeforetravelingtoan
areawheremalariatransmissionoccurs

Somepeopleprefertotakeadailymedicine

Goodchoiceforshortertripsbecauseyou
onlyhavetotakethemedicinefor7days
aftertravelingratherthan4weeks

Verywelltoleratedmedicinesideeffects
uncommon

Reasonsthatmightmakeyouavoidusingthis
drug

Cannotbeusedbywomenwhoarepregnant
orbreastfeedingachildlessthan5kg

Cannotbetakenbypeoplewithsevererenal
impairment

Tendstobemoreexpensivethansomeofthe
otheroptions(especiallyfortripsoflong
duration)

Somepeople(includingchildren)would
rathernottakeamedicineeveryday

Pediatrictabletsareavailableandmaybe
moreconvenient

Somepeoplewouldrathertakemedicine
weekly

Cannotbeusedinareaswithchloroquineor
mefloquineresistance

Goodchoiceforlongtripsbecauseitistaken
onlyweekly

Mayexacerbatepsoriasis

Somepeoplearealreadytaking
hydroxychloroquinechronicallyfor
rheumatologicconditions.Inthoseinstances,
theymaynothavetotakeanadditional
medicine

Somepeoplewouldrathernottakeaweekly
medication

Fortripsofshortduration,somepeople
wouldrathernottakemedicationfor4weeks

Chloroquine

Drug

Reasonsthatmightmakeyouconsiderusingthis
drug

Reasonsthatmightmakeyouavoidusingthis
drug
aftertravel

Doxycycline

Mefloquine
(Lariam)

Canbeusedinalltrimestersofpregnancy

Somepeopleprefertotakeadailymedicine

Goodforlastminutetravelersbecausethe
drugisstarted12daysbeforetravelingtoan
areawheremalariatransmissionoccurs

Notagoodchoiceforlastminutetravelers
becausedrugneedstobestarted12weeks
priortotravel

Cannotbeusedbypregnantwomenand
children<8yearsold

Somepeoplewouldrathernottakea
medicineeveryday

Fortripsofshortduration,somepeople
wouldrathernottakemedicationfor4weeks
aftertravel

Womenpronetogettingvaginalyeast
infectionswhentakingantibioticsmayprefer
takingadifferentmedicine

Tendstobetheleastexpensiveantimalarial

Somepeoplearealreadytakingdoxycycline
chronicallyforpreventionofacne.Inthose
instances,theydonothavetotakean
additionalmedicine

Doxycyclinealsocanpreventsome
additionalinfections(e.g.,Rickettsiaeand
leptospirosis)andsoitmaybepreferredby
peopleplanningtodolotsofhiking,
camping,andwadingandswimminginfresh
water

Personsplanningonconsiderablesun
exposuremaywanttoavoidtheincreased
riskofsunsensitivity

Somepeopleareconcernedaboutthe
potentialofgettinganupsetstomachfrom
doxycycline

Somepeoplewouldrathertakemedicine
weekly

Cannotbeusedinareaswithmefloquine
resistance

Goodchoiceforlongtripsbecauseitistaken
onlyweekly

Cannotbeusedinpatientswithcertain
psychiatricconditions

Canbeusedduringpregnancy

Cannotbeusedinpatientswithaseizure
disorder

Notrecommendedforpersonswithcardiac
conductionabnormalities

Notagoodchoiceforlastminutetravelers
becausedrugneedstobestartedatleast2
weekspriortotravel

Somepeoplewouldrathernottakeaweekly
medication

Drug

Reasonsthatmightmakeyouconsiderusingthis
drug

Itisthemosteffectivemedicinefor
preventingP.vivaxandsoitisagoodchoice
fortraveltoplaceswith>90%P.vivax

Goodchoiceforshortertripsbecauseyou
onlyhavetotakethemedicinefor7days
aftertravelingratherthan4weeks

Goodforlastminutetravelersbecausethe
drugisstarted12daysbeforetravelingtoan
areawheremalariatransmissionoccurs

Primaquine

Reasonsthatmightmakeyouavoidusingthis
drug

Fortripsofshortduration,somepeople
wouldrathernottakemedicationfor4weeks
aftertravel

Cannotbeusedinpatientswithglucose6
phosphatasedehydrogenase(G6PD)
deficiency

Cannotbeusedinpatientswhohavenot
beentestedforG6PDdeficiency

Therearecostsanddelaysassociatedwith
gettingaG6PDtestdone;however,itonly
hastobedoneonce.OnceanormalG6PD
levelisverifiedanddocumented,thetest
doesnothavetoberepeatedthenexttime
primaquineisconsidered

Cannotbeusedbypregnantwomen

Cannotbeusedbywomenwhoare
breastfeedingunlesstheinfanthasalsobeen
testedforG6PDdeficiency

Somepeople(includingchildren)would
rathernottakeamedicineeveryday

Somepeopleareconcernedaboutthe
potentialofgettinganupsetstomachfrom
primaquine

Somepeopleprefertotakeadailymedicine

IndoorResidualSpraying
Manymalariavectorsareconsidered"endophilic";thatis,themosquitovectorsrestinsidehousesaftertakingabloodmeal.These
mosquitoesareparticularlysusceptibletocontrolthroughindoorresidualspraying(IRS).

WhatIsIndoorResidualSpraying?
Asitsnameimplies,IRSinvolvescoatingthewallsandothersurfacesofahousewitharesidualinsecticide.Forseveralmonths,the
insecticidewillkillmosquitoesandotherinsectsthatcomeincontactwiththesesurfaces.IRSdoesnotdirectlypreventpeoplefrom
beingbittenbymosquitoes.Rather,itusuallykillsmosquitoesaftertheyhavefediftheycometorestonthesprayedsurface.IRSthus
preventstransmissionofinfectiontootherpersons.Tobeeffective,IRSmustbeappliedtoaveryhighproportionofhouseholdsinan
area(usually>80%).

Indoorresidualspraying

HistoryofIRS
IRSwithDDTwastheprimarymalariacontrolmethodusedduringtheGlobalMalariaEradicationCampaign(19551969).The
campaigndidnotachieveitsstatedobjectivebutitdideliminatemalariafromseveralareasandsharplyreducedtheburdenofmalaria
diseaseinothers.
ConcernovertheenvironmentalimpactofDDTledtotheintroductionofother,moreexpensiveinsecticides.Astheeradication
campaignworeon,theresponsibilityformaintainingitwasshiftedtoendemiccountriesthatwerenotabletoshoulderthefinancial
burden.Thecampaigncollapsedandinmanyareas,malariasoonreturnedtoprecampaignlevels.
AsaresultofthecostofIRS,thenegativepublicityduetothefailureoftheMalariaEradicationCampaign,andenvironmental
concernsaboutresidualinsecticides,IRSprogramswerelargelydisbandedotherthaninafewcountrieswithresourcestocontinue
them.However,therecentsuccessofIRSinreducingmalariacasesinSouthAfricabymorethan80%hasrevivedinterestinthis
malariapreventiontool.

InsecticideTreatedBedNets

Insecticidetreatedbednets(ITNs)areamajorinterventionformalariacontrol.Photocredit:MaggieHallahanPhotography
Insecticidetreatedbednets(ITNs)areaformofpersonalprotectionthathasbeenshowntoreducemalariaillness,severedisease,and
deathduetomalariainendemicregions.IncommunitywidetrialsinseveralAfricansettings,ITNshavebeenshowntoreducethe
deathofchildrenunder5yearsfromallcausesbyabout20%.

HowDoITNsWork?
Bednetsformaprotectivebarrieraroundpeoplesleepingunderthem.However,bednetstreatedwithaninsecticidearemuchmore
protectivethanuntreatednets.
Theinsecticidesthatareusedfortreatingbednetskillmosquitoes,aswellasotherinsects.Theinsecticidesalsorepelmosquitoes,
reducingthenumberthatenterthehouseandattempttofeedonpeopleinside.Inaddition,ifhighcommunitycoverageisachieved,
thenumbersofmosquitoes,aswellastheirlengthoflifewillbereduced.Whenthishappens,allmembersofthecommunityare
protected,regardlessofwhetherornottheyareusingabednet.Toachievesucheffects,morethanhalfofthepeopleinacommunity
mustuseanITN.

NetMaterialsandInsecticides
Netsmayvarybysize,shape,color,material,and/orinsecticidetreatmentstatus.Mostnetsaremadeofpolyester,polyethylene,or
polypropylene.
OnlypyrethroidinsecticidesareapprovedforuseonITNs.Theseinsecticideshavebeenshowntoposeverylowhealthrisksto
humansandothermammals,butaretoxictoinsectsandkillthem,evenatverylowdoses.Pyrethroidsdonotrapidlybreakdown
unlesswashedorexposedtosunlight.Previously,netshadtoberetreatedevery6to12months,orevenmorefrequentlyifthenets
werewashed.Netswereretreatedbysimplydippingtheminamixtureofwaterandinsecticideandallowingthemtodryinashady
place.TheneedforfrequentretreatmentwasamajorbarriertowidespreaduseofITNsinendemiccountries.Inaddition,the
additionalcostoftheinsecticideandthelackofunderstandingitsimportanceresultedinverylowretreatmentratesinmostAfrican
countries.
Recentstudieshavesuggestedthattheriseofpyrethroidresistancemayunderminetheeffectivenessofnets.Tohelpmanage
resistance,somenetproductsincorporatepiperonylbutoxide(PBO)alongwithapyrethroidinsecticide,butthereisnotyetevidence
thatthissignificantlyimprovesITNeffectivenessinareaswithhighlevelsofpyrethroidresistance,andWHOcurrentlydoesnot
considernetsthatincorporatePBOtobetoolsformanagingpyrethroidresistance.

LongLastingInsecticidetreatedNets(LLINs)
WHORecommendedLongLastingInsecticidalMosquitoNets,February2014
Severalcompanieshavedevelopedlonglastinginsecticidetreatednets(LLINs)thatmaintaineffectivelevelsofinsecticideforat
least3years,evenafterrepeatedwashing.TheWHOPesticideEvaluationScheme (WHOPES)hasgiveneitherfullorinterim

approvalto11oftheseLLINs foruseinthepreventionofmalaria.CDCiscurrentlytestingsomeoftheseandotherLLINsto
assesstheirperformanceanddurabilityinthefield.
LLINshavebeenassociatedwithsharpdecreasesinmalariaincountrieswheremalariaprogramshaveachievedhighLLINcoverage.
WHOnowrecommendsthatLLINsbedistributedtoandusedbyallpeople("universalcoverage")inmalariousareas,notjustbythe
mostvulnerablegroups:pregnantwomenandchildrenunder5years.LLINsaremostcommonlydistributedthroughmasscampaigns
approximatelyevery3years.
Between2008and2010,atotalof294millionnetsweredistributedinsubSaharanAfrica.FundingforLLINsgraduallyincreased
from2004when5.6millionnetsweredelivered,to2010,when145millionnetsweredelivered.However,fundingfornets,andother
malariapreventionandcontrolinterventions,islikelytoplateauorevendeclineinthenextfewyearsduetothecurrenteconomic
situation.OnewaytomaintainnetcoverageistoincreasethelifespanofLLINs.Arecentstudyestimatedthatupto$3.8billioncould
besavedover10yearsbyincreasingthelifespanofnetsfrom3yearsto5years.
Mobilizingresourcestoprocurethesenetsremainsamajorchallenge.Aftermuchdebate,WHOnowrecommendsthatLLINsbe
providedfree.MultilateralandbilateraldonorsandprogramssuchastheGlobalFundagainstHIV/AIDs,Tuberculosis,andMalaria
andthePresident'sMalariaInitiativesupportthepurchaseofLLINsformanycountries.Individualdonationsofnetscanbemade
throughorganizationssuchasCDCFoundation orMalariaNoMore .

Cost of Malaria Drugs

Drug Name

Drug Class

Price

Vibramycin
(doxycycline hyclate)

Tetracycline antibiotics

$44

Plaquenil
(hydroxychloroquine)

Antirheumatics

$31

Malarone
(atovaquone/proguanil)

Antimalarials

$125

Doryx
(doxycycline hyclate)

Tetracycline antibiotics

$218

Aralen
(Chloroquine
phosphate)

Antimalarials

$22

Qualaquin
(quinine)

Antimalarials

$117

Mefloquine

Antimalarials

$56

Acticlate

Tetracycline antibiotics

$713

Daraprim

Antifolate
Antimalarials

$841

Quinidine sulfate

Antiarrhythmics

Coartem

Antimalarials

$112

Morgidox

Tetracycline antibiotics

$361

Primaquine

Antimalarials

$19

$50

Cost of Impregnated Bed Nets

On average, between $3 and $6 per bed if ordered in bulk.
If ordered individually, $35.
Average effective lifetime, 3 years.

Cost of Indoor Residual Spraying

Approved insecticides
Currently, the WHO has approved twelve different insecticides for IRS.

Recommended
Insecticide

Class

dosage of active
ingredient (g/m )

2 ]

DDT

Organochlorine

Fenitrothion

Duration of
effective
action
(months)

Estimated cost

WHO

per house per 6 toxicity

months (US$)

rating

12

>6

$1.60

II

Organophosphate

36

$14.80

II

Malathion

Organophosphate

23

$8.20

III

Propoxur

Carbamate

12

36

$18.80

II

Bendiocarb

Carbamate

0.10.4

26

$13.80

II

0.020.025

36

$1.60

II

0.020.03

36

$8.60

III

Deltamethrin Pyrethroid

Lambdacyhalothrin

Pyrethroid