World Health Organization · 2025 edition · 171 pages
Comprehensive operational guidance for diagnosing, treating and preventing malaria in humanitarian emergencies and displaced populations.
- Issuer
- World Health Organization
- Edition
- 2025 edition
- Audience
- National malaria control programme managers, health cluster/sector coordinators, UNHCR health officers, humanitarian health practitioners (MSF, IRC, ICRC), WHO country office staff, ministries of health emergency operations centres, community health workers, and clinical providers in emergency settings.
- Evidence
- Based on WHO Guidelines for malaria (2023, GRADE-rated recommendations) adapted for emergency contexts; incorporates expert consensus from Working Group on Malaria Control in Humanitarian Emergencies (2022–2024) and field case studies from 24+ countries (Uganda, Mozambique, Nigeria, South Sudan, DRC, CAR, Yemen, Afghanistan, Somalia, others).
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 171-page field manual supersedes the 2013 WHO handbook and provides evidence-based, practical guidance for malaria control in humanitarian emergencies affecting the 80 million forcibly displaced persons in 43 malaria-endemic countries. It consolidates WHO recommendations with field-tested strategies across case management, chemoprevention, vector control, coordination, surveillance and community engagement.
The manual recognizes that malaria is frequently the leading cause of morbidity and mortality during emergencies, particularly in sub-Saharan Africa where 94% of global cases occur. It addresses three emergency scenarios: malaria in moderate-to-high transmission settings (non-epidemic), malaria epidemics in humanitarian crises, and malaria within broader public health emergencies (e.g., Ebola, COVID-19). Emphasis is placed on rapid deployment of diagnosis (RDTs preferred over microscopy), artemisinin-based combination therapy (ACT), insecticide-treated nets (ITNs), and mass drug administration (MDA) for outbreak control.
Key innovations include integration of malaria interventions within cluster/sector humanitarian responses, attention to comorbidities (especially severe acute malnutrition, which multiplies mortality risk), and operational research on emerging tools such as spatial repellents and malaria vaccines (RTS,S/AS01, R21/Matrix-M) for protracted emergencies. The manual stresses early coordination through national malaria control programmes, Health Clusters, and UNHCR Refugee Coordination Models, alongside pre-positioning of supplies and leveraging emergency funding mechanisms (CERF, Contingency Fund for Emergencies).
Key points
For clinicians — doses and thresholds as stated in the guideline
- All suspected malaria cases with fever (>37.5°C in past 48 hours) should receive confirmatory testing with RDTs (preferred) or microscopy before treatment; do not repeat HRP2 RDT within 28 days of prior full treatment.
- Uncomplicated P. falciparum malaria: treat with 3-day ACT (artemether-lumefantrine, artesunate-amodiaquine, dihydroartemisinin-piperaquine, artesunate-mefloquine, or artesunate-pyronaridine) for all ages including pregnant women (all trimesters).
- Severe malaria: immediate pre-referral treatment with rectal artesunate (10 mg/kg for children <6 years) or intramuscular artesunate (2.4 mg/kg), then urgent referral; at referral facility, intravenous artesunate 2.4 mg/kg at 0, 12, 24 hours, then daily until oral ACT can be tolerated.
- Mass drug administration (MDA): deploy in outbreaks/emergencies with >80% coverage using ACT plus single low-dose primaquine (0.25 mg/kg) to interrupt transmission; target children <5 years in high-transmission settings for initial MDA followed by monthly chemoprevention.
- Seasonal malaria chemoprevention (SMC): administer sulfadoxine-pyrimethamine + amodiaquine monthly during high-transmission season to children 3–59 months in Sahel and similar settings (≥60% of cases in ≤4 months).
- Vector control: distribute long-lasting insecticidal nets (LLINs) aiming for universal coverage (1 net per 2 persons); conduct indoor residual spraying (IRS) in structurally suitable shelters; implement larval source management in displacement camps with standing water.
- Children with severe acute malnutrition (SAM) and malaria have higher treatment failure risk and mortality; refer SAM children with any severe malaria signs for inpatient care; screen all children <5 years with malaria for acute malnutrition (MUAC <125 mm or weight-for-height <–3 SD).
- In P. vivax-endemic areas with known chloroquine resistance, treat with ACT; for radical cure give primaquine 0.5 mg/kg/day for 7 days (if G6PD status unknown) or 14 days (if G6PD-normal); alternatively tafenoquine 300 mg single dose (adults, if G6PD-normal).
Danger signs requiring immediate pre-referral treatment and urgent referral
Table extracted from the guideline
| With fever | Without fever |
|---|---|
| Confusion, agitation, lethargy | Breathing rate >20/min (adults) or >50/min (neonates), or central cyanosis, or severe respiratory distress |
| Stiff neck | Weak and fast pulse or capillary refill >2 seconds |
| Very weak (unable to stand or walk unaided) | Unconscious or convulsing now or recently |
| Unable to drink or vomiting everything | Severe pain: abdominal, thoracic, neck pain, or severe headache |
| Severe abdominal pain | |
| Fast and deep breathing or severe respiratory distress |
Source: World Health Organization, Malaria control in emergencies: field manual. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Supersedes the 2013 WHO handbook with updated evidence from 24+ countries experiencing emergencies and incorporates lessons from COVID-19, Ebola (Uganda 2022), and Cyclone Idai (Mozambique 2019).
- Expanded coverage of malaria in protracted emergencies (average displacement duration 10–26 years) and integration within IASC Humanitarian Programme Cycle and UNHCR Refugee Coordination Model.
- Inclusion of malaria vaccines (RTS,S/AS01, R21/Matrix-M) as potential interventions in moderate-to-high burden protracted emergencies where young children are at particular risk.
- New operational research chapter (Chapter 7) on emerging vector control tools: passive emanators (spatial repellents), attractive targeted sugar baits (ATSB), insecticide-treated textiles, and topical repellents.
- Enhanced guidance on HRP2/3 gene deletions in RDTs (≥5% prevalence in Horn of Africa: Djibouti, Eritrea, Ethiopia) requiring shift away from exclusive HRP2-based RDTs.
- Updated chemoprevention nomenclature: intermittent preventive treatment in infants (IPTi) renamed perennial malaria chemoprevention (PMC); addition of post-discharge malaria chemoprevention (PDMC) for children with severe anaemia.
- Detailed costing templates (Annex 2) for case management, chemoprevention, and vector control to support humanitarian funding proposals (CERF, Contingency Fund for Emergencies, Global Fund).
From the guideline
Verbatim
“Malaria is frequently a leading cause of death within the context of humanitarian emergencies.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has advised WHO on health in migration contexts and chaired Georgia's Public Health Institute during our malaria-free certification process, I see this manual as essential reading not only for deployment to endemic zones but for maintaining regional expertise. The South Caucasus and Eastern Europe face growing risks from climate-driven altitude shifts in transmission (now documented above 2000 m in East Africa) and from conflict-related displacement of populations carrying parasites from Afghanistan, Syria, and sub-Saharan hotspots. Georgian clinicians should particularly note the emphasis on RDT-based algorithms over microscopy in resource-constrained settings—a lesson applicable to our own rural and border health posts when managing imported cases—and the integration of malaria screening with nutrition assessment, given that severe acute malnutrition multiplies mortality risk severalfold. The manual's guidance on pre-positioning artemisinin-based regimens and training community health workers in danger-sign recognition is directly transferable to our regional technical assistance programmes. One caveat: the recommendation for mass drug administration at >80% coverage is operationally demanding even in stable settings; in active conflict zones with fragmented populations (as we've observed in South Sudan and Yemen case studies), achieving that threshold requires sustained community engagement and may necessitate phased, geographically targeted rollout rather than blanket campaigns.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia is certified malaria-free (since 2010) but this manual is highly relevant for Georgian health professionals deployed in WHO/UN emergency missions, for planning assistance to neighboring countries with re-emerging risks (e.g., Azerbaijan lowlands, parts of Armenia), and for managing imported malaria in migrants and refugees from endemic regions (Afghanistan, Syria, sub-Saharan Africa). The Public Health Institute of Georgia should maintain capacity to support regional partners in the South Caucasus and Eastern Europe on emergency preparedness (pre-positioning RDTs and ACTs, training on RDT interpretation and severe malaria recognition), and Georgian infectious disease specialists should be familiar with artemisinin-based regimens and G6PD testing for radical cure of P. vivax, given migration flows from Central Asia. National malaria elimination programmes in the region must integrate surveillance for imported cases within refugee health screening protocols and ensure Health Cluster coordination mechanisms can rapidly activate malaria response if climatic changes or conflict-driven displacement reintroduce transmission risk at altitudes previously considered safe (the manual notes cases now reported >2000 m in Ethiopian/Kenyan highlands due to warming).
Questions this guideline answers
Quick answers
When should I give pre-referral treatment for suspected severe malaria in a remote setting?
If a patient (especially child <6 years) has danger signs (prostration, impaired consciousness, multiple convulsions, severe anaemia, respiratory distress, shock, jaundice with organ dysfunction) and referral will be delayed, give rectal artesunate 10 mg/kg (children <6 years) or intramuscular artesunate 2.4 mg/kg (all ages), then refer urgently. Do not delay referral to give pre-referral treatment if transport is immediately available.
Can I use RDTs instead of microscopy in an acute emergency?
Yes, RDTs are preferred over microscopy in emergencies because they require minimal training, no electricity, and provide results in 15–20 minutes. Choose HRP2-based RDTs for P. falciparum detection in most settings, but use HRP2+pLDH combination RDTs in areas with known HRP2/3 deletions (e.g., Horn of Africa) or where P. vivax co-exists. Microscopy is reserved for quality assurance and investigation of RDT-negative cases with high clinical suspicion.
Should I give malaria chemoprevention in a displacement camp with high transmission?
Yes. If >10% RDT positivity in population screening and children <5 years are at risk, implement mass drug administration (MDA) with ACT plus single low-dose primaquine 0.25 mg/kg (contraindicated in infants <6 months, pregnant/breastfeeding women) at >80% coverage, followed by monthly chemoprevention. In Sahel-like seasonal settings (≥60% of annual cases in ≤4 months), use seasonal malaria chemoprevention (SMC) with sulfadoxine-pyrimethamine + amodiaquine for children 3–59 months during transmission season.
How do I manage a malnourished child with malaria?
Screen all children <5 years with malaria for acute malnutrition (mid-upper arm circumference <125 mm or weight-for-height <–3 SD). Children with severe acute malnutrition (SAM) and any severe malaria signs require inpatient referral for both malaria treatment (parenteral artesunate) and nutritional management. Children with SAM and uncomplicated malaria can be treated as outpatients with ACT but need close follow-up (daily if possible) and low threshold for referral, as SAM impairs drug absorption and increases treatment failure risk. Do not withhold malaria treatment in malnourished children.
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- Issuer
- World Health Organization
- Type
- Manual
- Edition
- 2025 edition
- Replaces
- Malaria control in emergencies: a country guide (handbook), 2nd edition, 2013
- Status
- Current
- Published
- 2025-08-11
- Languages
- English (French, Russian, Arabic translations planned)
- Scope
- Global, all malaria-endemic countries experiencing humanitarian emergencies (conflict, natural disasters, displacement, protracted crises); applicable to refugee, IDP, and host community settings in camp and out-of-camp contexts.
- Audience
- National malaria control programme managers, health cluster/sector coordinators, UNHCR health officers, humanitarian health practitioners (MSF, IRC, ICRC), WHO country office staff, ministries of health emergency operations centres, community health workers, and clinical providers in emergency settings.
- Pages
- 171
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-011283-4
- Evidence
- Based on WHO Guidelines for malaria (2023, GRADE-rated recommendations) adapted for emergency contexts; incorporates expert consensus from Working Group on Malaria Control in Humanitarian Emergencies (2022–2024) and field case studies from 24+ countries (Uganda, Mozambique, Nigeria, South Sudan, DRC, CAR, Yemen, Afghanistan, Somalia, others).
- Next review
- Not specified; living updates expected as WHO Guidelines for malaria are revised and new evidence from emergency settings emerges.
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
World Health Organization. Malaria control in emergencies: field manual. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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