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
Namawala, Tanzania
Population

4,758

Number of homes

868

Average household size

5+

Infection rate

40%

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

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.

Choosing a Drug to Prevent Malaria

Considerations when choosing a drug for malaria prophylaxis:

Recommendations for drugs to prevent malaria differ by country of travel and can be found in the country-specific tables of
the Yellow Book. Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that
country.
No antimalarial drug is 100% protective and must be combined with the use of personal protective measures, (i.e., insect
repellent, long sleeves, long pants, sleeping in a mosquito-free setting or using an insecticide-treated bednet).
For all medicines, also consider the possibility of drug-drug interactions with other medicines that the person might be taking
as well as other medical contraindications, such as drug allergies.
When several different drugs are recommended for an area, the following table might help in the decision process.

Drug

Reasons that might make you consider using this

drug

Atovaquone/Proguanil
(Malarone)

Good for last-minute travelers because the

drug is started 1-2 days before traveling to an
area where malaria transmission occurs
Some people prefer to take a daily medicine
Good choice for shorter trips because you
only have to take the medicine for 7 days
after traveling rather than 4 weeks
Very well tolerated medicine side effects
uncommon
Pediatric tablets are available and may be
more convenient

Reasons that might make you avoid using this

drug

Chloroquine

Doxycycline

Some people would rather take medicine

weekly
Good choice for long trips because it is taken
only weekly
Some people are already taking
hydroxychloroquine chronically for
rheumatologic conditions. In those instances,
they may not have to take an additional
medicine
Can be used in all trimesters of pregnancy

Some people prefer to take a daily medicine

Good for last-minute travelers because the
drug is started 1-2 days before traveling to an
area where malaria transmission occurs
Tends to be the least expensive antimalarial
Some people are already taking doxycycline
chronically for prevention of acne. In those
instances, they do not have to take an
additional medicine
Doxycycline also can prevent some
additional infections (e.g., Rickettsiae and
leptospirosis) and so it may be preferred by
people planning to do lots of hiking,

Cannot be used by women who are pregnant

or breastfeeding a child less than 5 kg
Cannot be taken by people with severe renal
impairment
Tends to be more expensive than some of
the other options (especially for trips of long
duration)
Some people (including children) would
rather not take a medicine every day

Cannot be used in areas with chloroquine or

mefloquine resistance
May exacerbate psoriasis
Some people would rather not take a weekly
medication
For trips of short duration, some people
would rather not take medication for 4
weeks after travel
Not a good choice for last-minute travelers
because drug needs to be started 1-2 weeks
prior to travel

Cannot be used by pregnant women and

children <8 years old
Some people would rather not take a
medicine every day
For trips of short duration, some people
would rather not take medication for 4
weeks after travel
Women prone to getting vaginal yeast
infections when taking antibiotics may
prefer taking a different medicine
Persons planning on considerable sun
exposure may want to avoid the increased
risk of sun sensitivity

Drug

Reasons that might make you consider using this

drug
camping, and wading and swimming in fresh
water

Reasons that might make you avoid using this

drug

Some people are concerned about the

potential of getting an upset stomach from
doxycycline

Cannot be used in areas with mefloquine

resistance
Cannot be used in patients with certain
psychiatric conditions
Cannot be used in patients with a seizure
disorder
Not recommended for persons with cardiac
conduction abnormalities
Not a good choice for last-minute travelers
because drug needs to be started at least 2
weeks prior to travel
Some people would rather not take a weekly
medication
For trips of short duration, some people
would rather not take medication for 4
weeks after travel

Mefloquine
(Lariam)

Some people would rather take medicine

weekly
Good choice for long trips because it is taken
only weekly
Can be used during pregnancy

Primaquine

It is the most effective medicine for

preventing P. vivax and so it is a good choice
for travel to places with > 90% P. vivax
Good choice for shorter trips because you
only have to take the medicine for 7 days
after traveling rather than 4 weeks
Good for last-minute travelers because the
drug is started 1-2 days before traveling to an
area where malaria transmission occurs
Some people prefer to take a daily medicine

Cannot be used in patients with glucose-6phosphatase dehydrogenase (G6PD)

deficiency
Cannot be used in patients who have not
been tested for G6PD deficiency
There are costs and delays associated with
getting a G6PD test done; however, it only
has to be done once. Once a normal G6PD
level is verified and documented, the test
does not have to be repeated the next time
primaquine is considered
Cannot be used by pregnant women
Cannot be used by women who are
breastfeeding unless the infant has also been
tested for G6PD deficiency
Some people (including children) would
rather not take a medicine every day
Some people are concerned about the
potential of getting an upset stomach from
primaquine

Indoor Residual Spraying

Many malaria vectors are considered "endophilic"; that is, the mosquito vectors rest inside houses after taking a blood meal. These
mosquitoes are particularly susceptible to control through indoor residual spraying (IRS).

What Is Indoor Residual Spraying?

As its name implies, IRS involves coating the walls and other surfaces of a house with a residual insecticide. For several months, the
insecticide will kill mosquitoes and other insects that come in contact with these surfaces. IRS does not directly prevent people from
being bitten by mosquitoes. Rather, it usually kills mosquitoes after they have fed if they come to rest on the sprayed surface. IRS thus
prevents transmission of infection to other persons. To be effective, IRS must be applied to a very high proportion of households in an
area (usually >80%).

Indoor residual spraying

History of IRS
IRS with DDT was the primary malaria control method used during the Global Malaria Eradication Campaign (1955-1969). The
campaign did not achieve its stated objective but it did eliminate malaria from several areas and sharply reduced the burden of malaria
disease in others.
Concern over the environmental impact of DDT led to the introduction of other, more expensive insecticides. As the eradication
campaign wore on, the responsibility for maintaining it was shifted to endemic countries that were not able to shoulder the financial
burden. The campaign collapsed and in many areas, malaria soon returned to pre-campaign levels.
As a result of the cost of IRS, the negative publicity due to the failure of the Malaria Eradication Campaign, and environmental
concerns about residual insecticides, IRS programs were largely disbanded other than in a few countries with resources to continue
them. However, the recent success of IRS in reducing malaria cases in South Africa by more than 80% has revived interest in this
malaria prevention tool.

Insecticide-Treated Bed Nets

Insecticide-treated bed nets (ITNs) are a major intervention for malaria control. Photo credit: Maggie Hallahan Photography
Insecticide-treated bed nets (ITNs) are a form of personal protection that has been shown to reduce malaria illness, severe disease, and
death due to malaria in endemic regions. In community-wide trials in several African settings, ITNs have been shown to reduce the
death of children under 5 years from all causes by about 20%.

How Do ITNs Work?

Bed nets form a protective barrier around people sleeping under them. However, bed nets treated with an insecticide are much more
protective than untreated nets.
The insecticides that are used for treating bed nets kill mosquitoes, as well as other insects. The insecticides also repel mosquitoes,
reducing the number that enter the house and attempt to feed on people inside. In addition, if high community coverage is achieved,
the numbers of mosquitoes, as well as their length of life will be reduced. When this happens, all members of the community are
protected, regardless of whether or not they are using a bed net. To achieve such effects, more than half of the people in a community
must use an ITN.

Net Materials and Insecticides

Nets may vary by size, shape, color, material, and/or insecticide treatment status. Most nets are made of polyester, polyethylene, or
polypropylene.
Only pyrethroid insecticides are approved for use on ITNs. These insecticides have been shown to pose very low health risks to
humans and other mammals, but are toxic to insects and kill them, even at very low doses. Pyrethroids do not rapidly break down
unless washed or exposed to sunlight. Previously, nets had to be retreated every 6 to 12 months, or even more frequently if the nets
were washed. Nets were retreated by simply dipping them in a mixture of water and insecticide and allowing them to dry in a shady
place. The need for frequent retreatment was a major barrier to widespread use of ITNs in endemic countries. In addition, the
additional cost of the insecticide and the lack of understanding its importance resulted in very low retreatment rates in most African
countries.
Recent studies have suggested that the rise of pyrethroid resistance may undermine the effectiveness of nets. To help manage
resistance, some net products incorporate piperonyl butoxide (PBO) along with a pyrethroid insecticide, but there is not yet evidence
that this significantly improves ITN effectiveness in areas with high levels of pyrethroid resistance, and WHO currently does not
consider nets that incorporate PBO to be tools for managing pyrethroid resistance.

Long-Lasting Insecticide-treated Nets (LLINs)

WHO-Recommended Long-Lasting Insecticidal Mosquito Nets, February 2014

Several companies have developed long-lasting insecticide-treated nets (LLINs) that maintain effective levels of insecticide for at least
3 years, even after repeated washing. The WHO Pesticide Evaluation Scheme (WHOPES) has given either full or interim approval
to 11 of these LLINs for use in the prevention of malaria. CDC is currently testing some of these and other LLINs to assess their
performance and durability in the field.
LLINs have been associated with sharp decreases in malaria in countries where malaria programs have achieved high LLIN coverage.
WHO now recommends that LLINs be distributed to and used by all people ("universal coverage") in malarious areas, not just by the
most vulnerable groups: pregnant women and children under 5 years. LLINs are most commonly distributed through mass campaigns
approximately every 3 years.
Between 2008 and 2010, a total of 294 million nets were distributed in sub-Saharan Africa. Funding for LLINs gradually increased
from 2004 when 5.6 million nets were delivered, to 2010, when 145 million nets were delivered. However, funding for nets, and other
malaria prevention and control interventions, is likely to plateau or even decline in the next few years due to the current economic
situation. One way to maintain net coverage is to increase the lifespan of LLINs. A recent study estimated that up to $3.8 billion could
be saved over 10 years by increasing the lifespan of nets from 3 years to 5 years.
Mobilizing resources to procure these nets remains a major challenge. After much debate, WHO now recommends that LLINs be
provided free. Multilateral and bilateral donors and programs such as the Global Fund against HIV/AIDs, Tuberculosis, and Malaria
and the President's Malaria Initiative support the purchase of LLINs for many countries. Individual donations of nets can be made
through organizations such as CDC Foundation or Malaria No More .

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

$19

Coartem

Antimalarials

$112

Morgidox

Tetracycline antibiotics

$361

Primaquine

Antimalarials

$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
2 ]

ingredient (g/m )

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