Pan American Health Organization · 2020
Operational guidance for national and local malaria programmes to sustain prevention, detection and treatment during COVID-19
- Issuer
- Pan American Health Organization
- Edition
- 2020
- Audience
- National malaria programme managers, local health authorities, malaria control personnel, public health decision-makers
- Evidence
- Expert consensus based on WHO malaria guidance adapted for COVID-19 context
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO technical document provides a four-step operational framework for malaria programmes in the Americas to maintain essential services during the COVID-19 pandemic whilst protecting health workers and preventing COVID-19 transmission. The guidance addresses anticipated disruptions including diagnostic capacity constraints, antimalarial supply shortages (especially chloroquine diverted to COVID-19 treatment), reduced mobility of health personnel, and difficulties maintaining vector control campaigns.
The document proposes a scenario-based approach with three levels of COVID-19 transmission risk: endemic areas with no COVID-19 cases (Scenario 1), endemic areas with imported or clustered transmission (Scenario 2), and endemic areas with community transmission (Scenario 3). For each scenario, specific adaptations are recommended for case detection, diagnosis, treatment, case investigation, vector control, and surveillance. Central recommendations include aligning malaria diagnostic points with COVID-19 triage flows, optimizing microscopy and RDT use when capacity is exceeded, introducing ACT for P. vivax when chloroquine is unavailable, simplifying treatment supervision, and maintaining LLIN distribution and IRS campaigns with physical distancing measures.
In exceptional circumstances where diagnostic capacity is overwhelmed in Scenario 3, the guidance permits presumptive treatment or targeted mass drug administration (MDA) in high-burden areas, but only with sufficient national antimalarial stocks (minimum 6 months) and appropriate national authorization. The overarching objective is to prevent malaria mortality whilst minimizing COVID-19 transmission risk to both health workers and patients.
Key points
For clinicians — doses and thresholds as stated in the guideline
- In malaria-endemic areas, all fever cases must be tested for malaria at COVID-19 triage/detection points using RDT or microscopy with appropriate PPE
- Introduce artemisinin-based combination therapy (ACT) plus primaquine for P. vivax treatment when chloroquine supplies are disrupted by COVID-19-related access problems or diversion to COVID-19 case management
- Temporarily abolish directly observed treatment and parasitological follow-up policies; provide complete treatment and telephone follow-up instead
- Simplify case investigation to one full interrogation at diagnosis with telephone follow-up; reactive case searches only for high-risk clusters with PPE-equipped institutional staff
- LLIN distribution and IRS campaigns should continue if possible with physical distancing (2 metres between people, groups limited to 10), daily temperature checks, and PPE for all personnel
- Presumptive antimalarial treatment may be considered as exceptional measure only if: diagnostic capacity exceeded, minimum 6-month national antimalarial stock available (including ACT for P. vivax), focused on high-positivity areas with sentinel monitoring
- Mass drug administration (MDA) permitted only in critical situations where malaria burden very high, health services overwhelmed, diagnostic capacity impaired, and subject to sufficient antimalarial stocks and national authorization
- Community agents for passive detection only with PPE; suspend activities according to local risk analysis and align with national COVID-19 provisions; consider fixed/mobile institutional diagnostic points as alternative
Actions according to COVID-19 risk scenarios in malaria-endemic areas
Table extracted from the guideline
| Scenario | Potential problems | Actions |
|---|---|---|
| Scenario 1: No COVID-19 cases | Possible shortage of medicines and RDTs; reduction in malaria control teams | Normal malaria actions with PPE; fixed diagnostic points at COVID-19 fever detection points; optimize microscopy if RDT shortage; introduce ACT+PQ for P. vivax if CQ shortage; LLIN and IRS as planned |
| Scenario 2: Imported/clustered COVID-19 | Medicine/RDT shortage; reduced capacity and mobility restrictions; suspected cases do not attend services | Fixed diagnostic points with PPE; communication to guide consults; optimize microscopy and RDT use; community agents passive detection only with PPE; simplify treatment monitoring; investigate cases only to prevent re-establishment; reactive case search high-risk clusters only; simplify notification and supervision |
| Scenario 3: Community COVID-19 transmission | Medicine/RDT shortage; cases do not attend; services overloaded; community agents at risk; malaria teams inactive | Fixed diagnostic points with PPE; suspend community agent and proactive detection; suspend treatment monitoring; case investigation only to prevent re-establishment; maintain LLIN/IRS if possible; exceptional measures: presumptive treatment only if ≥6-month stock; MDA only in critical situations with national authorization |
Source: Pan American Health Organization, Measures to ensure the continuity of the response to malaria in the Americas during the COVID-19 pandemic. Reproduced in summary form.
From the guideline
Verbatim
“Efforts to prevent, detect and treat malaria cases while preventing the spread of COVID-19 and ensuring the safety of service providers should be maintained.”
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 Chair of the Public Health Institute of Georgia and WHO consultant, I recognise this document as an important template for sustaining essential disease control programmes during pandemic response. Although Georgia eliminated malaria decades ago, the operational principles—integrating disease surveillance with emergency triage, protecting health workers through PPE protocols, maintaining supply chains under disruption, and adapting community-based services—are directly applicable to our tuberculosis, HIV, and hepatitis C programmes during COVID-19 or future pandemics. The scenario-based framework for prioritising interventions according to transmission intensity offers a pragmatic model for resource allocation decisions that Georgian public health authorities have faced since March 2020. The key implementation challenge for any health system is maintaining the discipline of routine disease surveillance when emergency pressures are acute, and ensuring that supply chain planning anticipates competing demands for medicines and diagnostics rather than reacting to shortages after they occur.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
Whilst Georgia eliminated malaria in the 1960s and remains malaria-free, this guidance holds direct relevance for national public health emergency preparedness planning, particularly the framework for maintaining essential disease control programmes during pandemic response. The scenario-based adaptation approach, integration of routine disease surveillance with emergency triage flows, and strategies for protecting health workers whilst sustaining priority services offer transferable lessons for managing tuberculosis, HIV, hepatitis C, and other communicable disease programmes during health emergencies. For Georgia’s role in regional health security and support to neighbouring countries, the document provides a tested operational model for balancing competing public health priorities under resource constraints.
Questions this guideline answers
Quick answers
When should presumptive antimalarial treatment be used during COVID-19?
Only as an exceptional measure when diagnostic capacity is exceeded despite optimizing microscopy and RDT use, national antimalarial stocks are sufficient (minimum 6 months including ACT for P. vivax), intervention is focused on high-positivity areas with rigorous case definitions, and positivity is monitored through sentinel samples.
Can LLIN distribution campaigns continue during COVID-19?
Yes, current and planned campaigns should continue if possible. Organize activities to avoid large gatherings, maintain 2-metre physical distancing, limit groups to 10 people, conduct daily temperature checks, ensure handwashing stations, and use PPE. Prioritize rural high-incidence areas with lower COVID-19 transmission risk if necessary.
How should malaria diagnosis be integrated with COVID-19 triage?
In malaria-endemic areas, adapt malaria care flows to perform RDT for all fever cases (with or without respiratory symptoms) at COVID-19 triage points. Develop screening algorithms based on local malaria and COVID-19 risk, maintain physical distancing, perform tests in separate areas, and ensure health workers use appropriate PPE.
What should be done if chloroquine is unavailable due to COVID-19 use?
Implement policy to use artemether-lumefantrine or other ACTs with primaquine for both P. vivax and P. falciparum. Accelerate procurement processes, ensure sufficient central and regional stocks, and rationalize ACT use by prioritizing for P. falciparum if chloroquine stocks remain adequate.
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- Regional Framework for the Monitoring and Re-Verification of Measles, Rubella, and Congenital Rubella Syndrome Elimination in the Americas
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish, Portuguese
- Scope
- Malaria-endemic countries in the Americas
- Audience
- National malaria programme managers, local health authorities, malaria control personnel, public health decision-makers
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on WHO malaria guidance adapted for COVID-19 context
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Measures to ensure the continuity of the response to malaria in the Americas during the COVID-19 pandemic, 24 April 2020. Washington, D.C.: PAHO; 2020. (PAHO/CDE/VT/Covid-19/20-0011). 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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